Who could imagine something this little could be a killer?

Here is a case that illustrates the importance of documentation in the medical record.

A fifty-six year-old man was receiving care at a rehabilitation center. He needed actual, hands-on care from the staff while eating. A sign placed over his bed said, “Stay with patient while eating. Choking Precaution.” The nursing admission assessment included the recommendations: “Eat slowly, take one small bite/sip at a time” and “chew food well before swallowing.” The initial admission assessment included the note that the upper partial plate dropped out of his mouth while he talked. The speech pathologist found the patient had poorly fitting dentures and dementia. The physicians assistant wrote a note that the patient would not stop eating on his own and was at risk for choking while eating. He was “very impulsive”.

After being at the facility for a month, the man was served dinner and left alone. He was found dead with a whole cherry tomato stuck in his throat. The family sued and alleged there was negligent supervision by the facility’s staff. This Georgia case settled for $850,000 around January 2014.

Purposes of the medical record
Although you as an attorney typically thinks of the medical record’s role in litigation, consider its other primary roles.

Share medical information
As you can see from this case, one of the major purposes of the chart is to convey important information about the patient – information that will assist other people to care for the patient. But putting information in the chart is not enough. Despite all of the information and warnings about this man’s risk for choking, the staff did not carry out the plan of care to stay with the patient while he ate.

Fulfill professional standards to document
Professional responsibility and accountability are among the most important reasons for accurate documentation. Documentation is part of the healthcare professional’s overall responsibility for patient care. The clinical record facilitates care, enhances continuity of care, and helps coordinate the treatment and evaluation of the patient.

One of the most significant professional functions of the healthcare professional is the evaluation of the patient’s responses to care. Professionals are responsible for managing increasingly complex patient issues and coordinating patient care among many levels of healthcare workers. Documentation must clearly communicate the judgment about and evaluation of the patient’s status.

Demonstrate compliance with regulations
Facilities are governed by a detailed set of standards from state, federal and national organizations. The medical record is designed to show that the staff are complying with these standards.

Reimbursement
Insurance companies and governmental agencies rely on the medical record to determine if the patient received care. Agencies look for discrepancies and inaccurate information. Billing audits of charts may reveal attempts to obtain reimbursement for care that was not given or justified.

Review of the medical record occurs early in a medical malpractice case and is a deciding factor in whether the plaintiff attorney will pursue a claim. The medical record is a record of care long after a healthcare provider’s memories fade about a specific patient. It forms a permanent way to review care given by healthcare professionals.

Initial medical record review
The attorney reviews the medical record to determine

• why the medical care was needed
• the specific care the patient received, according to the medical record
• whether the patient was correctly and timely diagnosed and treated
• whether the care was appropriate
• what went wrong

The medical record has an essential role in communication.

Need help to figure out how an error occurred? Our legal nurse consultants work with medical records and attorneys to create chronologies, develop questions for depositions of defendants and suggest items to obtain through discovery. Give us a call. We’re here to help.