Discharge instructions adequate? Don’t risk a suit
If a patient claimed that you never told him how to care for a wound that became infected, would you be able to prove otherwise?
"I have seen many malpractice cases where there is good documentation on admission, but then poor documentation prior to discharge from the ED," says Jackie Ross, RN, BSN, CPAN, a Chagrin Falls, OH-based risk management consultant who specializes in health care.
Inadequate discharge instructions may result in return visits to the ED, worsening of symptoms, and serious complications — all of which put you at risk for being named in malpractice lawsuits, says Patricia Iyer, RN, MSN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases.
Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals, says, "Clear discharge instructions are extremely important in defense of malpractice and EMTALA [the Emergency Medical Treatment and Labor Act] claims." warns.
Always document that the instructions were received and understood by the patient, says Kathie Eberhart, BSN, RN, CEN, legal nurse consultant based in Santa Rosa, CA. If the patient refuses to read the instructions or leaves against medical advice without receiving discharge instructions, document it, says Iyer. "In general, juries believe that patients should follow instructions and are often reluctant to find nurses negligent if the patient did not follow the advice of health care providers," she adds.
If there is a language barrier, be sure to document that an interpreter was present and instructions were understood, recommends Eberhart. Document which family members are present when discharge instructions are given, especially if the patient received any sedation or narcotics, says Ross.
Ask the patient to sign a form stating that they received discharge instructions, recommends Frew. "You may need solid proof that the patient actually received the instructions," he says.
What to include
Discharge instructions should include the following: The steps required to manage the illness or injury, medications prescribed in the ED, available community resources, and warning signs that signify the need for further treatment, says Iyer.
Pre-printed instructions may be used, as long as the information is given directly to the patient, says Iyer. "Encourage the patient to read through the information and ask questions before signing the form," she advises.
To reduce liability risks, take the following steps when giving discharge instructions:
•Clearly identify any activities that the patient should not do.
"People often don’t know what limitations are important to their recovery," says Frew. "These need to be laid out in black and white, to assure that the patient does not later suggest that they were injured because they did not know that an activity was dangerous to their condition."
If patients don’t follow your instructions, your documentation will clearly show that they were warned, says Frew.
•Give clear instructions for how to care for a condition.
Many malpractice lawsuits involve claims that the patient was unaware of how to treat a wound or who to contact for this information after discharge from the ED, says Ross. "It is important that accurate information, including at least two contact phone numbers, are included on the discharge instructions," she says.
If you give an instruction sheet, include a copy in the patient’s record also, advises Frew. "You are using more paper now, but it will save tons of effort later if a claim ever arises," he says. "Years after the fact, it is often difficult to recover the exact form that was used for instructions unless it is in the record itself."
•Make sure instructions are legible and in layman’s terms.
In the past few years, Frew has reviewed thousands of medical records from EDs and find a very pronounced trend toward totally illegible nurse entries, says Frew. "I have generally relied upon legible nurses’ notes to help me through the physician’s entries, but currently the legibility of many nurses’ handwriting has become as bad as the physician handwriting," he says.
If you use complex medical terminology or illegible writing, patients may claim they could not understand your instructions, says Frew. "Discharge instructions are totally useless, both from a patient’s perspective and from a defense perspective, unless the instructions are in language the patient can understand and in a form that the patient or the jury can actually read," he says.1
One solution is to utilize discharge summary programs that offer a comprehensive range of instructions, says Frew.
"Go with a system that has a large number of operating sites using the program and more than a year in application at those sites," he suggests. "Do your homework by checking those sites and talking to people who actually use the software before buying."
Reference
- Clarke C, Friedman SM, Shi K, et al. Emergency department discharge instructions comprehension and compliance study. Can J Emerg Med 2005; 7(1):5-11.
Sources
For more information on discharge instructions and liability risks, contact:
- Stephen A. Frew, JD, Vice President-Risk Consultant, Johnson Insurance Services, 525 Junction Road, Suite 2000, Madison, WI 53717. Telephone: (608) 245-6560. Fax: (608) 245-6585. E-mail: [email protected].
- Patricia Iyer, MSN, RN, LNCC, President, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Fax: (908) 806-4511. E-mail: [email protected]. Web: www.medleague.com.
- Jackie Ross, RN, BSN, CPAN, 17491 Merry Oaks Trail, Chagrin Falls, OH 44023. Telephone: (440) 708-9813. E-mail: [email protected].
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