March 25, 2019

Documentation is Key in Legal Protection

By Jessica Flage, Attorney at Law

The Medical Update article about balance disorders and dizziness states that 75 percent of people over the age of 70 have some sort of balance disorder which can cause dizziness, thereby making them prone to falls.

It is no secret that when an elderly person falls it can hasten their decline and be fatal.

The doctors interviewed for the article agree there are many potential causes for balance problems – everything from head trauma to inner ear disorders.

As an attorney who defends physicians in malpractice claims, a common mistake that these clients make when evaluating and treating a patient with balance disorders and dizziness (or any patient) is limited documentation. Just like in old school math class, it is important to show your work.

The reason? In a situation where medical negligence is alleged by the patient or their relatives, the defense of these cases often hinges on the documentary evidence. Simply put, documentation can be evidence.  It can show what you were thinking, what you were not thinking, what you ruled out, how you ruled it out, and why. Plaintiffs use documentation to prove that good care was not provided. Defendants use it to prove good care was provided and how.

Many cases are not brought to trial until years later, so proper documentation can also refresh your memory.

A heavy patient load and electronic medical records can make good documentation challenging. Check the boxes that apply and make notations where you can. Taking time to make notations protects you and your practice.

While working through the causes of complicated conditions such as dizziness and balance disorders think about who might see your records later. Countless lawsuits happen when it’s difficult to understand the physician’s thought process.

All procedures and tests performed need to be listed on the patient’s chart.  If you decided not to do a procedure or test, document that as well. When causes are ruled out, document your reasons for the conclusion.

When recording, include your assessments, identification of other health issues, plan of care, implementation, and evaluation. Medication risks should be discussed with the patient and that discussion should be noted. The patient’s decline should be recorded. If a specialist or expert is consulted, include his or her findings and recommendations.

Record the time of the visit, making sure date and time are stamped.  If you are unable to record during the visit, include the date and time you are recording and the visit.

Strong record keeping is crucial in dealing with abusive or non-compliant patients. It’s also important with patients with a complaint who do not show improvement.

Whether the patient is in the hospital, at home, or in a nursing facility, it is critical that all tests and care be documented by the physician, any midlevel providers, nurses, and staff.

Elderly patients may not understand who’s allowed access to their information. With HIPAA laws, only authorized family can learn about a patient’s medical condition and recommendations. It may be beneficial to discuss with elderly patients their desire to bring family into the fold. Start by asking: as things develop, who can we communicate with?

Lastly, take time to keep authorized family members involved.  They may seem content in your office, but that can change quickly with an adverse event.

Jessica Flage earned her law degree in 2007 at American University Washington College of Law. She focuses her practice primarily in the areas of medical malpractice defense litigation, healthcare and product liability defense with Goodman Allen Donnelly.