Articles Tagged With: Documentation
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Physicians Sometimes Need Help to Improve Documentation
Good charts and proper documentation take time, but technology and scribes can speed the process and improve the quality of documentation.
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Documenting Understaffing Could Sound Like Blame-Shifting to a Jury
Jurors are going to expect everyone in the ED is working together for the patient’s benefit. If the emergency physician has valid safety concerns, the medical record is not the place to voice those. Patient safety committees or the peer review process are better options, and generally are not discoverable during malpractice litigation.
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Legal Implications if Adolescents Seek Confidential Care
Generally, emergency clinicians are required to obtain parental consent for care provided to minors. However, there can be exceptions if the minor is seeking treatment for sexually transmitted infections, mental health, substance use disorders, sexual assault, or pregnancy. Several federal and state laws apply. Healthcare professionals are advised to be aware of the laws where they practice.
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Lack of EP Evaluation of Chest Pain Can Lead to Disaster
If an emergency physician never evaluates such a patient, leaving the care solely to a physician assistant or a nurse practitioner, this could lay the foundation for litigation.
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Obstacles to ED Admission Cause Legal Problems
When faced with this tricky situation, emergency physicians should carefully document discussions and remember they are responsible for clearly communicating about the patient’s condition, test results, and indication for admission.
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Documentation Mistakes Lead to Significant Malpractice Awards
Ensure charts are generated honestly, and check to make sure key care decisions are carefully documented regarding consent.
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Legally Protective Charting Sticks to the Facts
Charts containing emotional statements, accusations, and speculations might be compelling reading, but they are legally problematic.
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Legally Protective Charting Sticks to the Facts
Charts containing emotional statements, accusations, and speculations might be compelling reading, but they are legally problematic.
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Documentation Mistakes Lead to Significant Malpractice Awards
Ensure charts are generated honestly, and check to make sure key care decisions are carefully documented regarding consent.
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EP Could Be Deposed if Patient Was Misdiagnosed at Another ED
Beware making well-meaning statements or criticizing other clinicians in front of patients.