The lack of and inconsistent medical record
documentation continues to exist in the delivery of emergency department
care. Whether the emergency department is busy or not, there seems to
be a high number of emergency department records reviewed from a medical
legal standpoint either for standard of care issues, personal injury descriptions,
justification of payment or evidence of criminal injuries.
In analyzing medical records for more than 20 years, it is often apparent
that both emergency department doctors and nurses are challenged to document
care delivered in more complete and concise detail. Realizing by the very
nature of the specialty area where time is of the essence, it is not surprising
to see the continued lack of legible handwritten notes or the sketchy
legible clear electronic notes. Either forms of documentation hinder retrospective
audits of the emergency department medical record that would help support
the evidence that appropriate comprehensive care was in fact delivered
or that injuries were related to out-of-facility events.
This becomes a real issue in cases that are evaluated for medical and
nursing malpractice or where a personal injury occurred such as in a motor
vehicle accident or a work related injury resulting in the loss of a limb
that will later need to be explained. Consistent points in issue that
make it hard to defend or explain the extent of the injury are:
·
Lack
of documentation
·
Lack
of consistent legible
documentation
·
Failure
to document the time care was delivered
·
Lack
of legible signatures of healthcare providers
·
Failing
to intervene
·
Lack
of documenting when consultants are called in
·
Rewriting
entire entries
·
Delays
in evaluation, diagnosis, treatment
·
Failing
to confirm the accurate placement of peripheral intravenous catheters
in a vein instead of in an artery
·
Failure
to confirm accurate placement of central venous catheters prior to use
or administration of medications
·
Errors
in IV administration of medications dosage, dilution, rate
·
Lack
of communication
Remember the medical record is a tool that all healthcare providers use
to communicate any and all care provided to the patient. Its fundamental
purpose is to facilitate the continuity of healthcare, but its use lives
well beyond the immediate emergency department visit.
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
April 2009
Three
goofs in one: Poor charting, failure to name all defendants, and slack
citing to medical records
Rose
Clifford RN, LNCC
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
HINN
Letter
Constance
Watkins, RN, CLNC
You enter your patient’s
room and notice he looks confused and hands you a letter given to him
by a case manager.
Apparently, his admission is no longer covered by Medicare- how
can this be?
HINN letters are hospital
issued notices of non-coverage (also known as HABN-hospital advance
beneficiary notice) for a hospital stay or admission to the hospital.
If the hospital believes that Medicare will not pay for a hospital
admission or stay, a letter stating these facts must be presented to the
patient and signed by the patient.
Just because the patient has Medicare does not imply it covers
their current needs being provided by your organization.
The official letter will be on hospital letter head, and is required under
the Medicare rules. HINNs can be presented prior to admission, after admission
or during the hospital stay when a patient is believed to no longer need
acute inpatient hospital care. The continued stay type of HINN must be
issued in agreement with the patient’s physician.
As with any type of hospital denial, HINN letters can be questioned
or appealed by the patient or their family.
Why do nurses need to know about HINN letters?
Many nurses serve as case managers and are responsible for delivering/explaining
HINN to a Medicare patient if the admission or inpatient stay is in question.
Also, the issuer of the HINN letter must be knowledgeable as to how the
HINN appeals process works, the timeframe involved, and when the patient
will need to start paying for the hospital stay out of pocket.
The
HINN letter can often be overwhelming to a
patient.
A courteous, caring attitude must be used when one is issued along
with a knowledge base to understand the process.
For
additional reading:
http://www.cms.hhs.gov/Transmittals/Downloads/R982CP.pdf
http://www.gmcf.org/medicare_beneficiaries/media/hinn_flyer.pdf
October/November
2009
Healthcare
Road Rage
Constance
Watkins, RN, CLNC
Healthcare Road Rage is the medical equivalent of road rage, sometimes
it is passive-aggressive behavior and at other times extremely offensive.
Most hospital workers have experienced the behavior of physicians or other
professionals who throw instruments, refuse to answer pagers, swear and
make belittling remarks. Such behavior can cause medical errors patient
harm and even increase the cost of healthcare.
Frequently, physicians are the aggressors and nurses are the targets.
In fact, a Joint
Commission survey found that 50% of nurses had been targets of
this kind of intimidation, and 90% of nurses reported having witnessed
it. Many of these nurses or healthcare workers felt frustrated and feared
retribution if they reported the aggression.
Shortly after a very high profile legal case was decided (a perfusionist
sued a heart surgeon for his swearing, yelling and belittling remarks,
and won) The Joint Commission on Accreditation of Healthcare Organizations issued
a safety alert, requiring hospitals to adopt a zero-tolerance policy toward
workplace bullying.
By
January 2009, hospitals must have
complied with the new disruptive behavior standard (LD.3.15).
Hospitals
are required to establish a code of conduct that defines unacceptable
behavior, sets up a mechanism for workers to report inappropriate outbursts
and establishes consequences for misconduct. But even with these
standards in place, it could take years to establish behavior concurrent
with treating colleagues with civility and respect; unless disciplinary
actions are in place and enforced.
For
additional reading:
www.workplacebullying.org:
Trends:
Putting a Stop to Medical Road Rage by Melissa Knopper Clinician Reviews
January 17, 2009
www.boston.com/news/local/massachusetts/articles/2008/08/10