Nursing notes overlooked? Legal price could be costly
Less than 20% of nursing notes are read by physicians
Nursing notes often are ignored or, at best, casually reviewed by physicians, says Sam Bierstock, MD, founder of Champions in Healthcare, a consulting company in Delray Beach, FL, specializing in healthcare information technology. Fewer than 20% of nursing notes are read by physicians, according to a 2011 study.1
"In spite of their key role in patient care, nursing clinical notes are almost universally unread by physicians," says Bierstock.
In 2009, the Superior Court of Pennsylvania affirmed an $8.6 million judgment entered against a physician and a medical group in a wrongful death action that involved a physician's failure to read nursing notes.2 The case involved a 60-year-old patient recovering from surgery in a hospital's rehabilitation unit, who subsequently died from massive gastrointestinal bleeding. Stephanie M. Godfrey, JD, an attorney with Pepper Hamilton LLP in Philadelphia, PA, says, "The nursing notes, which indicated that the patient was growing paler each day, had not been reviewed by the attending physician."
In 1994, a Louisiana surgeon was held to have breached his duty of care, in part, because he did not read the nursing notes for his coronary artery bypass patient who developed postoperative wound infections and died of a heart attack about a month after surgery.3 "Signs of infection were contained in the nursing notes, but the physician did not record similar findings in his own notes, did not review the nursing notes, and did not pursue aggressive treatment of the patient's infections," says Godfrey.
According to the court, which granted an award of $174,508 to the patient's wife and $50,000 to each of the patient's seven children, the surgeon's actions had exacerbated the patient's critical condition and deprived him of a chance of survival.
Increased exposure
There often are discrepancies in descriptions of clinical findings between nursing notes and physician progress notes, warns Bierstock.
"Any disparity displays a clear lack of consistency in clinical observations and awareness of patient status," he warns. "This can lead to vulnerability to medical legal action for all parties involved."
If physicians don't read nursing notes, they might miss important information that wasn't discovered during their own encounters with the patient, such as subtle changes in a patient's condition, says Godfrey. "A physician who has analyzed all the facts at his disposal will be in a better position to guard against allegations that he misdiagnosed a patient or failed to fulfill his duty of care, than one who has acted without proper consideration of all the facts available to him," says Godfrey.
Lack of information due to failure to read nursing notes might result in misdiagnoses, unnecessary diagnostic tests, inappropriate prescriptions, and medical complications, all of which increase the physician's exposure to malpractice liability, she says. Godfrey gives these risk-reducing strategies:
• Physicians should be educated about the potential liability that can result from the failure to review nursing notes.
• Physicians should be encouraged to view nursing notes at each patient encounter and upon discharge to ensure accuracy.
"Physicians should look for any noted changes in the patient's condition which may prevent discharge or which should be addressed in the post-discharge instructions," Godfrey says.
• Training programs should be implemented to ensure that nurses are entering notes properly and physicians are able to view them.
• If there are inconsistencies between nursing and physician notes, the disagreeing parties should discuss their conflicting notes and, if necessary, visit the patient together to confirm findings.
"The discrepancy and any such discussions or follow-up with the patient should be documented," Godfrey says. "In addition, the agreed resolution of the discrepancy should be documented in the record by each of the parties."
References
- Hripcsak G, Vawdrey DK, Fred MR, et al. Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc 2011; 18:112-117.
- Hyrcza v. W. Penn Allegheny Health Sys. 2009 PA Super 119 (Pa. Super. Ct. July 1, 2009).
- Todd v. Sauls, 94-10 (La. App. 3 Cir. 12/21/94).
Sources
For more information on reviewing nursing documentation, contact:
- Sam Bierstock, MD, Champions in Healthcare. Phone: (561) 243-3673. Email: [email protected]. Web: www.championsinhealthcare.com.
- Stephanie M. Godfrey, JD, Pepper Hamilton LLP, Philadelphia, PA. Phone: (215) 981-4473. Fax: (215) 981-4750. Email: [email protected].
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