Articles Tagged With: Documentation
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Physicians Less Optimistic About Public Health
Burning the candle at both ends is catching up with physicians, some of whom expressed frustration with the way their medical facilities are addressing burnout, according to the results of a new survey.
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Primary Care Is on Life Support, But Case Management Could Be Antidote
Primary care is facing decline due to financial factors and clinician burnout. One solution is to assign case managers or care coordinators to primary care offices to improve communication between primary care providers, hospitals, and other healthcare entities.
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LWBS Patients Pose Risks for EDs Under EMTALA
Solid documentation is the best weapon against accusations a clinician violated the Emergency Medical Treatment and Labor Act and a patient who left the ED without being seen who files a malpractice lawsuit.
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Remember the Basics of Good Documentation
Proper documentation requires adhering to the basic goals of fully and accurately recording the patient encounter. Depending on the circumstances, chart notes should include a brief social narrative of relevant historical data, an explanation of the reason for the encounter, subjective complaints and observations reported by the patient, objective findings on physical examination by the clinicians, a diagnosis, treatment plan, and follow-up instructions for post-discharge care.
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Physicians Sometimes Need Help to Improve Documentation
Good charts and proper documentation take time, but technology and scribes can speed the process and improve the quality of documentation.
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Improve Documentation for Compliance, Med/Mal Defense
Good documentation is the foundation of any solid malpractice defense and proper continuity of care argument, so risk managers constantly urge clinicians to make meticulous notes. But there are many ways in which documentation can fall short. Frequent education and adjustment to technological changes can be key to making good documentation.
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Documenting Understaffing Could Sound Like Blame-Shifting to a Jury
Jurors are going to expect everyone in the ED is working together for the patient’s benefit. If the emergency physician has valid safety concerns, the medical record is not the place to voice those. Patient safety committees or the peer review process are better options, and generally are not discoverable during malpractice litigation.
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Legal Implications if Adolescents Seek Confidential Care
Generally, emergency clinicians are required to obtain parental consent for care provided to minors. However, there can be exceptions if the minor is seeking treatment for sexually transmitted infections, mental health, substance use disorders, sexual assault, or pregnancy. Several federal and state laws apply. Healthcare professionals are advised to be aware of the laws where they practice.
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Lack of EP Evaluation of Chest Pain Can Lead to Disaster
If an emergency physician never evaluates such a patient, leaving the care solely to a physician assistant or a nurse practitioner, this could lay the foundation for litigation.
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Obstacles to ED Admission Cause Legal Problems
When faced with this tricky situation, emergency physicians should carefully document discussions and remember they are responsible for clearly communicating about the patient’s condition, test results, and indication for admission.