How to reduce risk for malpractice claim
(Editor’s note: This is the second part of a two-part series on claims involving routine procedures. Last month, we told you the contributing factors. This month, we tell you ways to reduce the risk of malpractice claims.)
There are two key ways to reduce the risk for a malpractice claim: documentation and clear communication, says Carmen Lester, RN, JD, CPHRM, co-owner of Yin Yang Medical Services.
Lester recommends these practices:
• Documentation should be objective, specific, compete, legible, authenticated, dated, and timed.
"Electronic health records assist in achieving these requirements," says Lester.
• The medical record should include patient history, assessments, diagnoses, patient progress, the reason for and results of diagnostic testing, the patient’s response to treatment, any changes in interventions, patient non-compliance, and a plan of care until the next encounter.
• Communication with the patient and family needs to be upfront, sincere, and continued throughout the course of the doctor/patient relationship.
"Keep in mind that the natural tendency after an adverse outcome is avoidance," says Lester. "This only makes the patient and family feel isolated, helpless, and angry, which is when attorneys are contacted."
While anyone can go to a plaintiff’s attorney for what they perceive as a poor outcome, keep in mind that for a malpractice claim to survive, all four elements of negligence must be met, says Jan Kleinhesselink, RN, CPHQ, co-owner of Yin Yang Medical Services, a Nebraska-based provider of risk management services. These elements are duty, breach of that duty, causation, and damages.
