Articles Tagged With: Documentation
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ED Nurses Feel Unprepared for Mental Health Complaints
Engaging with the patient can help ED nurses avoid these risky situations. Nurses can notice subtle signs of escalation, treat with medications when appropriate, offer food, perform regular assessments, and facilitate hygiene. It also is important for ED nurses to demonstrate they did everything in their power to transfer the patient to a higher level of care, if that is what the patient needs. -
Neurology Consult Delays Can Become Issue in Claims
If a stroke patient alleges failure to administer tissue plasminogen activator, whether a timely neurology consult was obtained likely will be a central issue in the litigation. Here are some issues that can arise during litigation. -
Claims Involving Physician Assistant Care Continue
Malpractice claims involving physician assistants in the ED have increased in recent years and are continuing to come up, according to interviews with legal experts. Most emergency physicians who voice concerns are worried about finding themselves defendants in lawsuits — when they never saw or even knew about the patient. -
Problems When Calling Patient a ‘Drug Seeker’
Is this drug-seeking label truly needed to complete the chart? What message are you trying to convey, and to whom? Who is going to read that chart once you close it, and why?
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Checkbox Charting Is Problem for ED Malpractice Defense
Make sure the ED uses modified templates to allow clinicians to add free-form text. Carefully review the record for accuracy before signing the note (including automatically populated checkboxes), either contemporaneously or close in time to the encounter. Finally, maintain a strong compliance program with regular medical record audits, including a review of electronic health record systems.
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Template Charting on Nursing Notes Complicates Med/Mal Defense
Instead of making blanket statements about review of nursing notes, the emergency physician should document accurately. If the physician did not actually review the nursing notes, stay silent on it.
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Do Not Promise Success, and Document Well
There are two things healthcare professionals can do to position themselves for a good defense in case of a malpractice lawsuit. First, do not promise patients success or even imply it. Also, be careful when creating policies and procedures.
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TJC Offers Guidance on Accreditation and Effects from COVID-19
COVID-19 has affected hospitals and health systems in many ways, extending to the accreditation requirements and processes of The Joint Commission (TJC). Responding to many questions and concerns from accredited facilities, TJC recently offered answers in a webinar. The topics were wide-ranging, from the waiver of certain requirements to telehealth and documentation.
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Finger-Pointing in Nurse Charting Is Opportunity for Plaintiff
Emergency nurses and physicians may not understand the liability implications of using charts to air grievances. A unified defense is recognized as the best approach for all defendants in ED malpractice claims, but finger-pointing notes make it difficult. Physicians and nurses should meet briefly before each shift to discuss the importance of teamwork, not only regarding patient care but also documentation.
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Patients, Families Viewing Ethics Consult Notes in Real Time
In reading ethics notes, clinicians often glean insights on how the ethics service contributes to patient care. Patients, along with their surrogates and proxies, will be able to learn from such consultations. For some ethicists, this may be a good time to reassess the goals of ethics notes.