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There are, of course, a number of chart documentation methods and the goals of the various methods are all the same: 1) to memorialize the patient encounter for future reference by other caregivers; 2) to provide information for billing purposes; and 3) to create a legal document that allows quality review whether in the medical setting or in the courtroom.
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Whether you are interviewing emergency medicine physicians, mid-level providers, or technicians in your ED, certain questions or remarks can get you into legal trouble. What should you avoid saying during the hiring process?
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Recently, over two dozen ED staff members at Palisades Medical Center in North Bergen, NJ were suspended for "sneaking a peek" of the medical record of George Clooney, who was being treated for injuries he sustained after a motorcycle accident.
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Not infrequently, parents are reluctant to proceed with medical treatment for their children in the emergency department (ED). When the treatment is clearly indicated, and when parental reluctance progresses to outright refusal, ED physicians are faced with difficult choices.
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How can a misread on an EKG years prior, which led to no immediate negative outcome, be held up at a distant time in the future as malpractice? It doesn't seem right to the practicing ED physician.
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Caring for patients with little privacy other than thin curtains in a crowded emergency department seems to fly in the face of the requirements of the Health Insurance Portability and Accountability Act (HIPAA). But what are the actual liability risks of this practice?
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The evaluation of a febrile child is an extremely common scenario in most emergency departments. Emergency physicians must decide which children require a work-up, the nature of that work-up, and the need for antibiotics with or without hospitalization. This process often is in the context of evaluating many febrile children, with only subtle clues as to which child truly may be ill. Unfortunately, it is common for inadvertent errors in judgment to end up in the courtroom as a subject of malpractice lawsuits. This months issue focuses on some of the risks and controversies in the evaluation of the febrile child.
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Headache is a common chief complaint encountered by emergency physicians (EPs). It may be a symptom of benign diseases such as migraine headaches or a common virus. Unfortunately, it also may represent other, more life-threatening illnesses, including subarachnoid hemorrhage. Delineating which patients need radiologic imaging, spinal fluid testing, and even angiography is part of the challenge encountered by the EP. This issue will outline strategies for reducing risk in the headache patient. Specifically, diagnosis and management of subarachniod hemorrhage will be detailed.
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Documentation requirements for every patient encounter have increased, leaving less time for the actual practice of medicine. While documentation is a burden to physicians and nurses, it does have unlimited value. Documentation allows for appropriate billing for the time and efforts of the physician, nurse, and other medical specialists. Thorough documentation allows for maximum reimbursement without fear of subsequent legal retribution from various government programs. Furthermore, the medical record is an essential historical document of the patients previous medical encounters. Documentation of the patient encounter and treatment will provide a defense to potential subsequent litigation that may ensue. The emergency physician may be unaware that a medical expert is reading a case of a previous patient encounter right now. The documentation of the care provided may preclude the plaintiffs expert from making assumptions and opinions adverse to the physician. This months issue will detail the importance of documentation and outline strategies for reducing risk.
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Recent cases involving the undertreatment of pain, the over-treatment of pain (and thereby the creation of addicts), and whether drug seekers have any legal rights to pain management have created management problems for the emergency physician. This issue of ED Legal Letter will look at some of these cases. The author addresses recent changes in pain management medications, and readers will be able to develop a practical approach to the patient with pain with fewer worries about the legal consequences.
