Legal Tips

March 2009
The Admission Process: The choice between outpatient (OP), observation status (OBS) and inpatient (INPT admissions
Constance Watkins, RN, CLNC

     It is every nurse’s responsibility to make sure admission orders are complete and correct. 
If an admission is incorrect or needs to be changed, it is the nurse who must ensure that the
physician is aware and corrects the admission status. Hospital reimbursement funds depend
on accurate admission orders and inaccuracies may result in overpayment, underpayment,
or perception of fraud.

      The admission process begins when the physician writes the admission order. This order must include:

§         Level of care (OP, OBS or INPT)

§         Physician’s signature and date signed

§         Admitting diagnosis

     Some examples of Outpatient Services are:

§         X-rays or scans

§         Laboratory tests

§         Other procedures performed 

§         Patient is discharged to home the same day

     The Inpatient Admission is determined by:

Severity of signs/symptoms 

Medical history

Need for inpatient diagnostic studies or tests

Medical predictability of an adverse event

     Observation Status can be an unplanned event or an evaluation period to determine if 

an inpatient admission is necessary. Examples:

1.    An unplanned event occurs in the patient’s post-op recovery period that 

requires the need for periodic monitoring and assessment by the clinical staff.          

2.    The order is written in the post-op period and signals the beginning of the 

OBS period.

3.    An evaluation period occurs as the result of an outpatient condition needing

 additional evaluation; most commonly 24 hours or less.    

     Observation status is appropriate if a serious condition can probably be ruled out in < 24 

hours or if that identified medical condition is likely to abate within < 24 hours of therapy. 

Nurses must keep the physician actively involved in the status of the initial order being met 

or if the patient needs inpatient admission, then a new order must be written.

     Inpatient vs. Observation is ongoing but doesn’t have to be a problem if the nurse/physician 

remembers the following:

R/O Rule Out = R/O Remember Observation

Additional information can be found in the Medicare Benefit Policy Manual,

 Chapter 1:  Inpatient Hospital Services Covered Under Part A, pages 6-7.  

 www.cms.hhs.gov/Manuals/downloads/bp102c15.pdf 

In a recent Wisconsin medical malpractice case, a hospital staff nurse could not defend herself with her own charting to prove that she had timely paged a neurosurgeon concerning a patient.

A jury found her 60% at fault under a $1 million award and the trial court found her negligent as a matter of law. However, the plaintiffs’ attorney did not name her in the suit. The plaintiffs were then in the strange position, on an appeal alleging procedural blunders by the trial court, of trying to exonerate the negligent nurse so as to shift all blame to the named parties and thus fatten the award. On top of this, the plaintiffs’ attorney angered the appeals court by sloppy citations to medical records.

In Skrzypchak v. Jensen, 2009 WL 130130 (Wis.App.), plaintiff Dale Skrzypchak showed up at an ER with cauda equina syndrome. CES is a neurosurgical emergency where time is of the essence. The longer surgery is delayed, the more nerve damage can occur.

Poor charting

Skrzypchak was admitted to Wausau Hospital complaining of lower back pain, tingling and trouble urinating. A staff nurse was found negligent “as a matter of law” by the trial court for a failure to report an abnormal medical condition, which is a breach in the standard of care.

The appeals court said, “The undisputed evidence was that… [the nurse]… did not report the abnormal neurological signs she discovered at 4:50 and 8:30 p.m. Experts testified that her failure to contact a physician constituted a breach of the standard of care.”

The nurse insisted that she made proper and timely pages about Skrzypchak to a neurosurgeon as she had been ordered to do, and electronic phone records showed that some pages were made on the hospital floor by someone, but the nurse’s charting did not reflect that she herself made the pages. Thus, the nurse’s lack of charting notes were weighed more heavily than electronic phone records, and the trial court told the jury not to speculate on who made the pages based only on phone records.

Skrzypchak suffered medical complications that were exacerbated by a delay in his eventual surgery, the delay was attributed to a lack of communication by the nurse and, for want of charting, the lack of communication could not be rebutted.

Poor trial strategy?

The appeals court noted that “The issue of negligence is rarely decided as a matter of law.”

But here, a nurse was found negligent by a directed verdict on uncontested facts and held 60% liable by a jury. However, she luckily was not sued and thus was a nonparty to the action — the plaintiff attorneys had sued only two subcontractor doctors and not the nurse or her hospital employer.

The appeals court said, “At the outset, it is worth noting that the Skrzypchaks’ grievance with the judgment stems from the jury allocating 60% of the causal negligence to [the nurse], an employee of Wausau Hospital. The Skrzypchaks did not sue [the nurse] or Wausau Hospital, and therefore 60% of their damages were uncollectable.”

Cite it right

The plaintiffs’ attorney in the case also was fined $500 for violating the rules of appellate procedure.

The appeals court said: “We note that our task in writing this decision was unnecessarily complicated by the failure of the Skrzypchaks’ attorney… to provide appropriate citations to the record, as required by the rules of appellate procedure.”

“For example, [the attorney] repeatedly cites to trial exhibits 1 through 3, each of which is a binder of medical records. He does not, however, cite to page numbers within those exhibits, even though exhibit 2, for instance, is nearly 600 pages.”

“Failure to follow the rules of appellate procedure is grounds for dismissal of the appeal, summary reversal, striking of a paper, imposition of a penalty or costs on a party or counsel or other action as the court considers appropriate. Here, we deem a sanction of $500 against [the attorney] to be an appropriate penalty for these rule violations….”

Reprinted with permission of The Medical-Legal News. For more information or subscription information please go to www.medical-legalnews.com or call 859-234-2345.

 June/July 2009