Articles Tagged With: Documentation
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Template Charting on Nursing Notes Complicates Med/Mal Defense
Instead of making blanket statements about review of nursing notes, the emergency physician should document accurately. If the physician did not actually review the nursing notes, stay silent on it.
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Do Not Promise Success, and Document Well
There are two things healthcare professionals can do to position themselves for a good defense in case of a malpractice lawsuit. First, do not promise patients success or even imply it. Also, be careful when creating policies and procedures.
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TJC Offers Guidance on Accreditation and Effects from COVID-19
COVID-19 has affected hospitals and health systems in many ways, extending to the accreditation requirements and processes of The Joint Commission (TJC). Responding to many questions and concerns from accredited facilities, TJC recently offered answers in a webinar. The topics were wide-ranging, from the waiver of certain requirements to telehealth and documentation.
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Finger-Pointing in Nurse Charting Is Opportunity for Plaintiff
Emergency nurses and physicians may not understand the liability implications of using charts to air grievances. A unified defense is recognized as the best approach for all defendants in ED malpractice claims, but finger-pointing notes make it difficult. Physicians and nurses should meet briefly before each shift to discuss the importance of teamwork, not only regarding patient care but also documentation.
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Patients, Families Viewing Ethics Consult Notes in Real Time
In reading ethics notes, clinicians often glean insights on how the ethics service contributes to patient care. Patients, along with their surrogates and proxies, will be able to learn from such consultations. For some ethicists, this may be a good time to reassess the goals of ethics notes.
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Coping with Aftermath of COVID-19 Reimbursement Changes
Health plans issued many waivers during COVID-19 — for authorizations, for copays, and for telehealth. But patient access departments soon found the devil was in the details, with varying time frames and stipulations all coming into play. The result: A flood of denied claims. Learn how registrars are starting to sort through the mess.
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Finger-Pointing in Nurse Charting Is Opportunity for Plaintiff
Emergency nurses and physicians may not understand the liability implications of using charts to air grievances. A unified defense is recognized as the best approach for all defendants in ED malpractice claims, but finger-pointing notes make it difficult. Physicians and nurses should meet briefly before each shift to discuss the importance of teamwork, not only regarding patient care but also documentation.
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Documentation Can Determine Outcome of Missed Myocardial Infarction Lawsuit
Some charts might indicate there was chest pain and an abnormal ECG, but the patient was discharged with no explanation. Plaintiffs can use this to make a case the emergency physician missed classic presentation of myocardial infarction. Counter this allegation with specific documentation outlined here.
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Best Practices for Documenting Allergies
A good quality improvement project for 2021 would be to focus on bolstering the way the organization handles patients’ allergy histories.
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AAAHC’s Allergy Benchmarking Study Highlights Inconsistencies
In a recent study, investigators found allergies sometimes were not verified or updated at each visit, there was a reliance on using the acronym NKDA (no known drug allergies), without references to other allergies or sensitivities, and overall allergic reaction documentation was inconsistent.