Tag Archives: medical records

Facing challenges in documenting medical care

Every healthcare professional knows that, at some point in their medical practice, they may be called on to defend patient care. When time passes and our ability to accurately recall information is diminished we should be able to rely on documentation of events to answer questions. There are practices you can adopt that can make it easier to make a good habit of properly documenting everything that happens before, during and after patient care.

Documenting everything is not the only key component to keeping proper records. Your medical record entries must be adequate representations of what happened. Imagine a jury reviewing records in a medical malpractice case, assume they do not spend much of their time reading medical records. How might they react to inadequate records? What may be obvious to you may not be to them. When others are charged with judging your credibility, the quality of your medical records can either enhance or diminish your credibility.

Examples of detrimental documentation practices, as identified in the recently article published by The Doctors Company, The Faintest Ink.[i]

  • Gaps and delays in documentation
  • Illegible entries
  • Dictation with blanks
  • Unflattering or judgmental patient descriptions
  • Entries appearing to vent negative feelings
  • Altered records and records missing documents or entries

To ensure proper documentation, each time and every time, the best practice is to develop a system for entering and recording information. Almost like a checklist, you can determine the rules and procedures for managing information. Identify details regarding when, where, how, what and why information is recorded. While it may seem like extra work, at some point your medical records could be under review and read in isolation of other information. Therefore, every single time it is helpful to identify why an entry is being recorded.

Features and benefits of good documentation habits

Increased communication with patients and increased continuity of care should increase understanding, decrease misunderstanding. In many medical malpractice cases, the root of the problem leading to a complaint can often be identified as failure in the communication process.

One way to improve communication is to use dictation equipment to make your patient notes. When you dictate notes right in front of patients you are more likely to read the details into the notes so that the patient can understand everything. If, on the other hand, you are making dictation and sound cryptic or unclear, a patient could become nervous and worried about not having a clear understanding of their doctor visit.

When making entries, beware of the easy mistakes that you can make when using forms and templates. A simple mistake in recording information on a form can cause problems. If there is an error in checking boxes on one form, could there be more errors on other forms? Making independent notes every time you record patient information better insures accuracy and credibility of information.

It is a good idea to audit and review medical records to ensure that documentation procedures are consistently used. In the audit process, a reviewer may detect entries that may require a second look. If there is an error or missing information, it is always best to make a new record and attach it as an addendum to the original. Do not change or alter records when there is active or pending litigation.

For more tips on documenting patient medical records or if you have questions about exposure and liability in the event of a patient complaint or claim for malpractice, please be in touch with Michael V. Favia and Associates, P.C.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] Source for article summary: The Doctors Company, The Faintest Ink, By Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.

Preventing medical malpractice claims with smart strategies

Physicians and their patients all make their best efforts to exchange information to ensure great patient care. At points in the healthcare process, there can be mistakes leading to dissatisfied patients. In many cases, miscommunication and errors can be corrected with little harm done. In other instances, malpractice complaints are filed. Everyone involved in the patient care process would prefer to avoid a negative incident or malpractice complaint. Being diligent in assuring good patient care involves adopting strategies in reducing risks of medical mistake.

In a recent article published in Medical Economics, several doctors and healthcare professionals shared their perspectives on improving patient care, communication and documentation, ideally reducing malpractice lawsuits.[i]

The following is a summary of 5 strategies to reduce malpractice lawsuit threats:

Proper documentation means documenting everything

“Every doctor is taught that if you didn’t put it in the chart, you didn’t do it.[ii]” In error in noting a patient’s chart begs the question of how to correct the typo or wrong word choices. The best practice is to make a separate notation which you identify and incorporate by reference in the original notation. Changing or deleting an error can lead to trouble.

Noting everything in the patient’s chart should also include any communication with patients and family members. Ask them to explain the information back to you to make sure they understand. Make a note in the chart describing exactly how the communication took place. If you note everything with the sense that any other physician could step into patient care without missing a beat, you are engaging in a positive habit that should help avoid medical mistakes and malpractice claims.

Transparency with patients and facilitating access to charts and notes

Does your physician share access to notes and charts? Would you know how to read and interpret those notes if they were made available to you as a patient? Transparency in healthcare services allows patients and their physicians to all understand the reason and course of care. A patient may elect to seek another medical opinion and if they do, the more information you share with them as the primary physician, the better you may be protected from later claims of medical mistake or malpractice. It may take longer to create notes that others can understand, but the benefit in transparency and documentation makes this a best practice.

Expressing empathy when sharing information with patients

When a physician discovers a medical error, they may face tough decisions in communicating errors with patients and their families. While the natural inclination may to apologize and express remorse for a medical mistake, too many physicians are worried about an admission of error which could lead to a malpractice claim. While contrition may be, appropriate and appease concerned patients and families in many instances, there may be times your apology is insufficient to resolve dissatisfaction.

Illinois is one of many states with “sorry laws” protecting physicians from exposure in malpractice cases for expressing apologies and remorse to patients and families. The form of an apology should be sincere and honest. You can effectively express empathy without saying too much that may confuse or give the patient and family the wrong idea. Apologies when due, can be an appropriate best practice. Notwithstanding, being aware of hospital administration and policies that may affect your patient communications is important.

Managing the risks associated with electronic health records

The intended purpose of electronic health records (EHRs) is to solve information and documentation concerns. The portability and access to EHRs should help prevent medical mistakes and malpractice claims. Nevertheless, there are EHR pitfalls to avoid, such as using auto-populating fields in the forms and copying and pasting. Drop down menu errors can also be a problem and cause the wrong information to be populated in the EHRs, which can lead to medical mistakes and malpractice. Imagine another physician relies on wrong information in a patient’s EHRs and misses a drug allergy or gives a patient wrong dose of medications.

Maintaining positive relationships with patients and their family

Reducing uncertainty and increasing understanding is good for physician-patient communication and care. When family members are involved, it is a good practice to let them know what is happening in the care process and what issues may arise and affect the patient’s health. Showing the patient and their family attention and explanation of what is happen and what is anticipated in patient care may give the patient and family solace in knowing their concerns are important and well-attended. Being realistic and transparent is always a best practice to increase understanding and prevent medical mistakes and malpractice claims.

Adding these strategies to your practice

Since so much documentation is required in healthcare, it should be reasonably simple to include these proactive patient care strategies to any healthcare practice. Adding reminders to engage in these tasks is helpful in adopting them as positive habits in practice. Health law, litigation and licensing attorney, Michael V. Favia works with patients, physicians and healthcare organizations to identify and manage risks and to prevent and resolve conflicts when they arise. An audit of a physicians practice can lead to solutions in preventing malpractice.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] Medical Economics, 5 strategies to reduce malpractice lawsuit threats, By Liz Seegert, Nov. 10, 2016.

[ii] See HNi above.

PODCAST: Workers Compensation: Independent medical examinations with Anna Lozoya

The licensing consultants interviewed in this monthly program, previously worked for the Illinois Department of Professional Regulation, and will represent and/or defend licensed professionals in cases involving the Illinois Department of Financial and Professional Regulation, Illinois Department of Public Aid and Illinois Department of Public Health.

Topics covered in this 30-minute interview – Click/tap here to listen anytime! 

  • Introducing Anna Lozoya, JD, RN, Of Counsel to Michael V. Favia & Associates;
  • Describe the independent medical examination (IME) process in workers compensation;
  • My expertise in reading medical records and IME reports, independently;
  • The importance and value of an objective third party observer;
  • The benefits of having a nurse advocate in the exam room during an IME.

Anna Lozoya, JD, RN, Of Counsel to Michael V. Favia & Associates, works for the firm, on independent medical examination (IME) matters in workers compensation cases. Anna leverages her experience reading medical records and IME reports to help the firm maximize its results for workers compensation plaintiffs. Anna is an attorney and a registered nurse in the State of Illinois and works with a variety of health related legal matters including personal injury, medical malpractice, and regulatory matters with the Illinois Department of Financial and Professional Regulation and the Illinois Department of Public Health. In addition, Anna is experienced in real estate law and is bi-lingual Spanish speaker. Anna earned her law degree from the DePaul University where she focused in health law and regulation.

Michael V. Favia & Associates are available to advise and represent health care professionals and the general Chicagoland community with a variety of legal issues. With offices conveniently located in the Chicago Loop, Northwest side and suburbs, you can schedule a discrete meeting with an attorney at your convenience and discretion.

For more about Michael V. Favia & Associates’ professional licensing work, please visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You may also connect with Attorney Michael V. Favia on LinkedIn and on Avvo.com where you may also read client endorsements and reviews.