Lack of communication may mean liability.

Lack of communication can be a major reason for problems in patient care that lead to lawsuits. And a key reason for lack of communication is poor documentation.

For healthcare providers, the medical record is not only a history of the patient’s diagnoses and care. It is the main vehicle used for communication between healthcare providers in order to be kept informed about the patient’s condition and key changes.

Consider the implication this has as hospitals introduce the use of electronic medical records (EMRs).

Formerly, healthcare providers relied on reading the handwritten narrative notes of all the patient’s providers; all patient information and diagnostic testing reports were readily available in the chart.

Now, providers may need to remember to look for entries in the EMR as well. This adds time and delays to already very busy practitioners’ days. It also means the possibility of increased errors.

Documentation and EMRs

I was recently speaking with an attorney about this very issue. He pointed out that a consulting physician wrote a narrative note that did not include key information that he later dictated into the EMR. Most of the treating team members relied on the handwritten consultation note…to the detriment of the patient.

Consider this…is it reasonable to expect healthcare providers to look for patient information in multiple places? Does it make sense to have patient information that is not cohesive and readily available in one place? Who has time to click through many computer screens, especially in an emergency?

The bottom line is that in order to prevent “dropping the ball” in patient care, members of the healthcare team must find ways to promote excellence in their communication, and document as if their patient’s life depends on it…it does!

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.

Jane Heron

Jane D. Heron, RN, BSN, MBA, LNCC is a legal nurse consultant at Med League.