Prescribing pain medication? Be sure this documentation is in chart
Prescribing pain medication? Be sure this documentation is in chart
When a physician is sued for negligent prescribing, a particular piece of documentation invariably becomes critically important, says Catherine J. Flynn, Esq., an attorney at Weber Gallagher in Warren, NJ.
“Plaintiffs always zero in on the documentation of the history, with respect to the medications the patient is taking,” she says.
Flynn is seeing an increasing number of medical malpractice claims involving allegations of negligent prescribing, in the office and hospital setting. “Physicians should be exceedingly careful,” warns Flynn. “The standard of care is evolving as we learn more about the negative effects of these drugs.”
Here she gives items that, if documented in the chart, can make negligent prescribing allegations easier to defend:
• Evidence that a thorough history was obtained.
The standard of care requires that at some point prior to prescribing any medication to a patient, physicians ascertain what medications the patient is taking, and if dealing with an issue that involves pain management, what medications the patient has taken in the past, says Flynn.
Negligent prescribing lawsuits typically involve patients with catastrophic injuries, such as respiratory depression resulting in profound neurologic impairment, and cases often hinge on whether the patient’s medication history was obtained, says Flynn. “If a medication history isn’t obtained or isn’t documented, providers are not protecting themselves from that type of allegation in front of a jury,” she says.
• Documentation that an appropriate clinical workup was done.
“Relying just on the patient’s report of pain or clinical presentation is not necessarily the best idea. If indicated, the appropriate diagnostic tests should be done” to investigate a patient’s complaints, says Flynn.
• A patient’s refusal to comply with treatment recommendations.
Clear documentation that a patient refused a diagnostic test that could establish an underlying condition such as a herniated disk, for example, can help the physician’s defense.
“Otherwise, the chart will show that the test was not done as ordered, but with no discussion as to why the patient didn’t have it — yet the physician continued to prescribe the medication,” says Flynn.
When a physician is sued for negligent prescribing, a particular piece of documentation invariably becomes critically important, says Catherine J. Flynn, Esq., an attorney at Weber Gallagher in Warren, NJ.Subscribe Now for Access
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