Articles Tagged With: Documentation
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Assessment, Documentation, and Protocols: All Tied to ED Malpractice Payouts
Malpractice claims are more likely to succeed if documentation is insufficient, if an assessment was inadequate, or if something was not handled according to policy or protocol.
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Simple Care, Concern Refute Perception of Bias that Fuels Lawsuits
It is not hard to imagine patients suspecting racial bias if they experience a rushed exam, long delays, or poor communication in the emergency department. Race is much more likely to become an issue if a provider behaves disrespectfully toward the patient.
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EMS Documentation Can Complicate Defense of ED Claim
Unpacking the various reasons why emergency medical service providers could become involved in emergency department malpractice lawsuits.
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Lawsuits Allege Negligent ED Care Caused Hospitalized Patient’s Poor Outcome
When emergency department patients are admitted but not yet transferred, that is a point of weakness for facilities.
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Wrong Box Checked in Chart? Common, Careless Error Complicates Defense
There are two types of discrepancies that can cause major problems for the defense during malpractice litigation. One, a discrepancy between the emergency physician's (EP) documentation and nursing documentation. Two, a discrepancy between the EP and obvious reality.
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Surgery Centers Can Improve Patient Record Documentation
From a nursing perspective, medical recordkeeping is more about risk management than it is about complying with regulations. All medical records from surgery centers should tell the stories of patients and include details about their episodes of care.
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Ethics Recommendations Span Years for Some Patients
When someone requests an ethics consult, the patient’s social and clinical history is important to know. So is the history of ethicists’ involvement. It is not uncommon for a consult service to be called multiple times over several to assist with a care question that resurfaces.
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Payers, Hospitals Disagree About Whether Patient Meets Inpatient Criteria
Payers are refusing to pay claims for gastric bypass, joint replacement, and even cataract extraction. Why? Because documentation in the record does not support the need for surgery.
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Missing Clinical Documentation Reason for Many Claims Denials
More health plans are asking for certain pieces of clinical documentation before paying claims. If it is not there, the claim is denied. What are the specific issues arising?
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Defensive Charting Can Lead to Unintended Consequences for Everyone
If EPs do not see the nursing notes, they will not be able to address statements claiming they did nothing to address a patient’s deteriorating condition.