Delays in charting can result in lawsuits, monetary penalties

The significance of well timed and complete documentation is a frequent subject of dialog in well being care. It’s simple to grasp how an incomplete document of a affected person’s situations and medicines could cause issues for a subsequent care supplier. Nevertheless, well being care professionals could also be much less accustomed to the authorized penalties that may consequence from even a short delay in finishing a radical document of a affected person encounter.

Medical documentation creates a document of all details about a affected person {that a} future care supplier could have to make selections about remedy. Correct documentation is a necessary step to making sure the usual of care is met. A failure to doc could cause hostile outcomes, which might in flip result in malpractice claims. Nevertheless, even when a failure to well timed and completely doc a affected person encounter doesn’t instantly have an effect on subsequent care, it may nonetheless result in a time-consuming and dear lawsuit.

A current case involving a affected person who went to an emergency division (ED) with a grievance of again ache is a chief instance. The affected person arrived at his native ED and defined that earlier within the day he had strained his again when he slammed on his brakes to keep away from a low-speed automotive crash. After analysis, the affected person was given ache treatment, which relieved the ache rapidly. The affected person’s vitals and a short description of the encounter have been charted shortly after the affected person was despatched dwelling with directions to observe up along with his main care physician.

The ED physician, consistent with his typical follow, deliberate to make use of his handwritten notes so as to add a extra detailed description of the encounter to the chart the next day. Sadly, a short time later the affected person returned to the identical hospital through ambulance after his spouse discovered him unresponsive. Efforts to revive the affected person have been unsuccessful. It was subsequently decided that the affected person’s again ache and loss of life have been brought on by a dissecting thoracic aneurysm relatively than muscle spasms from the automotive crash.

When the ED physician who had initially seen the affected person returned to the hospital for his shift the next day, he discovered what had occurred. The physician then added the late entry narrative of the encounter to the chart, however a a lot totally different model of the encounter appeared. The physician famous that he had been involved a couple of potential thoracic aneurysm and had basically begged the affected person to bear testing, which might have seemingly revealed the affected person’s true situation. In response to the physician’s late entry, the affected person’s concern about paying an insurance coverage deductible and nervousness about being within the hospital made the affected person insistent that he be launched as quickly as potential with none diagnostic testing.

When a lawsuit was filed by the affected person’s spouse, primarily based on the alleged negligent failure to diagnose the aneurysm, the timing of the physician’s late entry was uncovered. The late entry, mixed with the spouse’s testimony that her husband by no means had nervousness about hospitals and wouldn’t have been involved about an insurance coverage deductible, transformed a normal failure to diagnose declare into a much more difficult declare. The brand new allegation was that the ED physician had fabricated the extra particulars of the encounter to keep away from legal responsibility for the affected person’s loss of life. The allegation of improper bolstering of the medical document created a really actual chance that the affected person’s spouse could be awarded thousands and thousands of {dollars} in punitive damages. This led to the affected person’s spouse credibly looking for nicely over $10 million from the physician and the hospital. After years of litigation, the case ended with a multimillion-dollar settlement.

Though the physician documented the encounter, the untimeliness of the entry—and its probably fabricated info—created extra legal responsibility than if the document had not been up to date. When he discovered of the affected person’s end result, the ED physician seemingly would have been higher served by consulting along with his hospital’s threat administration staff earlier than making any change to the affected person’s medical document. If this had been executed, the end result of the case seemingly would have been considerably totally different.

In right now’s fast-paced atmosphere, a practitioner’s time and a spotlight are treasured sources that needs to be put to finest use. Though chart completion could look like a chore that may be postpone till later, this choice can backfire. Delaying the completion of a chart may end up in spending weeks in a courtroom if a lawsuit arises. Even when the calls for of offering affected person care require that documentation be delayed, suppliers needs to be conscious when finishing after-the-fact charting. When unsure, consulting with threat managers can scale back the potential for an allegation of improper modification of a affected person’s information.