Failure to follow up can lead to lawsuits
Failure to follow up can lead to lawsuits
When patients leave the ED early, what your staff do afterward can make the difference between insulating yourself against a lawsuit and encouraging one, says Robert A. Bitterman, MD, JD, FACEP, a lawyer and emergency physician who is president of Bitterman Health Law Consulting Group in Harbor Springs, MI, and also vice president of Emergency Physicians Insurance Company (EPIC) in Auburn, CA.
Bitterman says these are some of the most common errors that lead to lawsuits after patients leave the ED before care is completed:
simply discharging the patient who insists on leaving early, without having the person sign an against-medical-advice form and without documenting the patient's refusal to follow medical advice;
not having the AMA form witnessed;
letting the patient leave without informing him or her of the risks;
failing to determine the patient's ability to make informed medical decisions, or not documenting that process in the medical record;
not involving the family in helping convince the patient to stay for medical care;
failing to properly document that the patient left freely or could not be found;
not reviewing the charts of early leavers to look for potentially serious conditions that need immediate follow-up;
not involving the ED physician, leaving the matter to nurses;
failing to review the test results of early leavers;
not documenting the AMA, or the attempt to obtain an AMA signature, in the chart.
Have specific response plans
Bitterman says ED staff must have prescribed steps for dealing with early leavers, so they can document their adherence to a set policy. He recommends following these steps:
For those who leave before examination, the staff should check the waiting room three times and page the patient at least once. A physician should review the chart immediately to determine if it is urgent to find the patient.
When a patient leaves after examination or treatment begins but without notifying anyone (elopement), a physician should review the chart and test results as soon as possible. If warranted, the staff should contact the patient to convey the test results. Document any attempts to reach the patient, even each unsuccessful attempt, and any instructions given the patient.
For patients who leave against medical advice but make their intentions known, the physician must be involved in trying to get them to stay. If possible, include the patient's personal physician in the conversation. Be specific in explaining the risks of leaving; broad statements such as, "You could die," are not enough, no matter how blunt. Explain exactly what could happen and how that could lead to death or serious harm. Have the patient sign an AMA form, or have a staff member sign the form stating that the patient refused. Provide appropriate discharge instructions, and invite the patient to return to the ED at any time for care.
The overriding concern in these situations is the need for documentation, Bitterman says. In many cases, the physicians and staff were diligent in trying to persuade the patient not to leave, but the medical record did not reflect those efforts. Once a case comes to litigation, what really matters is what is written in the chart, he says.
When patients leave the ED early, what your staff do afterward can make the difference between insulating yourself against a lawsuit and encouraging one, says Robert A. Bitterman, MD, JD, FACEP, a lawyer and emergency physician who is president of Bitterman Health Law Consulting Group in Harbor Springs, MI, and also vice president of Emergency Physicians Insurance Company (EPIC) in Auburn, CA.Subscribe Now for Access
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