Rattlesnake Review: Medical Legal Documentation – Don’t Get Bit

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PA-Urgent-Care-Medical-Legal-Documentation-Case-Study

The Situation

This is a case of a 44 year old male PA working urgent care that took care of a 56 yo female secretary with an accidental hand laceration from a kitchen knife.  It was discovered there was a flexor tendon injury, and hand surgery was immediately consulted.  The patient was seen on a Saturday, and the hand surgeon instructed the PA to close the hand and he would correct the tendon injury on Monday.  All was well documented and orders followed, including the PO antibiotic the surgeon ordered.

The hand surgery didn’t go well, and the patient had a motor deficit in their injured finger.  This injury was on her dominant hand.  Thus a case was initiated against the PA (interestingly not against the hand surgeon.)

The charting was perfect.  The consultation was appropriate.  The follow up (per the specialist) was by the book.  But, there was a problem.

The Mistake

During deposition, the review of systems was explored in detailed. This was a paper charting system, and the PA slashed a lot of “negative” boxes, such as headache and abdominal pain. It became clear in deposition that the PA didn’t ask these questions, and this was a case of “slash and burn” charting.

The defendant attorney felt the PA wouldn’t have been a dependable witness, and thus decided to settle the case out of court for $60,000.  The PA was reported to the National Provider Data bank because of the payout. Ouch.

What can we learn from this?

Well, the legal system isn’t concerned about right or wrong.  It’s a money thing.  Let’s be very clear about this.  There was no malpractice.  There was no direct correlation between the PAs actions and the damages.  But, in law, it’s perception.  And, it’s the perception of the jury that matters most.

The take home point is to document what you do. Period. I get the urgency of patient care when you are backed up 20 patients.  We need to be mindful of the documentation – clinical details, pertinent negatives and positives, as well as a detailed documentation of medical decision-making. This is the key to proper documentation and moving your chart from negligence to judgment. 

For details on how to document in the safest way possible, CLICK HERE.

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John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.
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