Mitigating Medical Malpractice Risks Through Documentation

Presented by: Chamiza Pacheco de Alas, Esq.Associate University CounselUNMHSC Office of the University CounselMitigating Medical Malpractice Risks Through DocumentationAtty Work Product: ConfidentialMed Mal Claims and Lawsuits Process Overview at UNM Health SystemTort Claim Notice Received within 90 days of alleged injuryLitigation Hold Email goes out requesting preservation and production of documents NOT in medical record. This is a legal evidentiary requirement, does not mean you are being named/sued/targeted, etc. Certification and documents returned within two weeks.Key providers (people we think have best/most information) interviewed.Decision made to recommend settle, deny or sit on it to State RMD, hopefully within 90 days.Subsequent lawsuit may be filed within 2 years of incident (for adults)

Communication Best PracticesNeed an effective way for patients/family members to reach team (and eventually attending) at any time.Need a specific time frame established for seeing patients who are new admitted, critically ill, or experiencing significant changes.Sit at eye level with patients when communicating.Use active listening.Ask patients to repeat back what you have said.Treat patients concerns seriously.Encourage family involvement.

Best Practices for ConsultationsTry to avoid curbside consultations that go beyond questions aimed at the general education of the requesting physician. (i.e.no questions about: specific tests or studies, record review would be best practice, diagnosis confirmation is requested).Document when a consult is requested in the record, and when it is received (if possible). Important to get accurate timelines in the record. If consult is refused, document that and the stated reasons. Consultants should be doing parallel documentation.

Best Practices For DocumentationMedical Records tells the story of the patients care and should do so accurately and meaningfully.DO NOT cut and paste (particularly from medical student notes, usually by residents)it is very obvious. Check notes before you co-sign for cutting and pasting. Be particularly mindful in cases with conflict or difficult social situations.If you disagree with something a medical student or resident has stated relating to patient care, document in an addenda or new note.Note times where relevant .Use a neutral tone in documentation, particularly where there are conflicts between servicesjust the facts.Medical record is not confidential or privileged, do not put things that should be confidential and privileged, such as advice from Office of the University Counsel, in the medical record.Be careful about how you document advice received from non clinical entities (i.e. risk management)at times that advice is misstated putting the institution in a bad situation. Mock case: What should be in the note and how (from a medical-legal perspective)?Mary Lamb, 72, came into the E.D. at 1AM complaining of chest pain, shortness of breath, and trouble sleeping. She stated she spent the day chasing sheep. The E.D. paged Dr. Smith, a resident, at 4AM asking for a consult regarding admission. Dr. Smith saw the patient at 6AM. Cardiology had been consulted by the E.D. but had not yet seen the patient when the resident saw him. Mary Lamb has a history of falls and reports she has been told she has some sort of blood clot problem. She doesnt believe it. She reports taking a variety of homeopathic medications but cant remember them all. She is requesting to go home because she is tired of waiting and the gurney in the E.D. is uncomfortable. Mock Case: Documenting Social IssuesMiles McQueen is a 19 year old developmentally disabled man being cared for by his parents, who are divorced. There is no documented power of attorney. There has been no formal assessment of his capacity. He has been admitted to your service due to his uncontrolled diabetes. You have instructed both parents that he must be on a very strict diet and insulin management regime. Nursing reports to you that his mother was seen feeding him ho hos at lunch, and then giving him insulin she brought from home. When confronted by nursing she stated that the insulin fixed the sugar from the ho hos. When you spoke to her and told her she had to stop feeding him food from home and dispensing insulin she stated hes my kid, I get to decide what happens to him in here. You become concerned and call legal, you are advised to formally evaluate capacity and to consider an APS referral. You page psychiatry and are told they cannot do a capacity evaluation without knowing what the decision is they are evaluating his capacity in reference to. Later that night, you receive a report from nursing that the mother was feeding her son an in ice cream sundae and when confronted by nursing staff replied f*&k off, hes my kid, Ill do whatever I want. Im taking him home in the morning Nursing stated they and her son were both fearful. Additionally, they smelled alcohol on her breath. The next morning, you call Adult Protective Services. They state they wont be investigating as he is in a safe place. What do you document? How? Example of good social documentationID: 3 wk PHM presented with acute L humerus fx, admitted for NAT. Currently on medical hold. 24 hr events:Pt remained clinically stable overnightPediatrics, CART and CYFD had prolonged discussion with multiple CYFD officers regarding their original assessment of returning patient to parents under supervision of a safety monitor. CYFD persisted in adhering to their initial plan. Pediatrics placed medical hold on patient. APD contacted. CYFD revised discharged plan and required the father to leave the home premises prior to pt returning home. Father cannot be alone with pt. without supervision.

Discussion/Questions?