Articles Tagged With: Documentation
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Three Common Missteps to Avoid with Med Mal Cases
Medical malpractice allegations can set off a cascade of obligations and possible pitfalls, and it can seem like there is too much to handle all at once. Paying attention to three potential missteps can ease some of the burden.
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How Case Managers Can Help Victims of Trafficking
Case managers can learn skills and tactics for helping patients who have been trafficked. For example, investigators used an online training module to educate ED staff about human trafficking. Participants reported more confidence in identifying a possible human trafficking victim, noting they were more likely to screen patients for human trafficking.
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Delays in Acute Stroke Treatment Contribute to Malpractice Claims
Recent research findings underscore the importance of always considering stroke in the differential diagnosis of altered mental status, even when the patient does not arrive by EMS.
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ChatGPT Provides Solid Responses to Virtual Medical Questions
Artificial intelligence tool provided empathetic, quality answers to online queries, which could help clinicians save time on electronic health record documentation work.
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Should Ethicists Hide Consult Notes from Patients?
Ethics consults often are accompanied by conflict, intense emotions, sensitive or controversial topics, and disagreements about values. Ethics notes tend to incorporate more narrative and explicit analysis than other clinical notes. For the sake of transparency, instead of shielding notes, consider excluding details that are likely to cause harm.
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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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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.