Court Appearance and Importance of Documentation - page 2

Working in Remote Areas While working for Health & Welfare Canada as a community health nurse, I received advanced training for outpost nursing at Dalhousie University in Halifax, Nova Scotia. In... Read More

  1. by   JustBeachyNurse
    Quote from Midiosa
    I work in a med mal defense firm, and my boss pushes the exact opposite: just because it wasn't documented, doesn't mean it wasn't done. It comes up in depositions a lot, especially where we have assessments from our ER docs that were essentially left blank. A lot of them will later say that even though the form wasn't completed, they still did it, etc. and that sometimes they don't have time to complete the chart, especially in an emergent situation.
    That makes no sense. Where is the evidence the work was done a year later. The opposing counsel must have a field day with that logic. My sister is s prosecutor. You would lose in court against her if you presented blank documentation and claim it was done.
  2. by   RiskManager
    Quote from Midiosa
    I work in a med mal defense firm, and my boss pushes the exact opposite: just because it wasn't documented, doesn't mean it wasn't done. It comes up in depositions a lot, especially where we have assessments from our ER docs that were essentially left blank. A lot of them will later say that even though the form wasn't completed, they still did it, etc. and that sometimes they don't have time to complete the chart, especially in an emergent situation.
    Yes, this is the Plan B that we use when the charting is not done: we argue that it is our usual and customary practice to do X, Y or Z; we can think of no reason why we would not have followed our usual and customary practice in this instance; and therefore just because it is not charted does not mean it was not done.

    This is done to try and salvage a situation in which the charting is poor or non-existent. This line of argument does not carry near as much weight in the eyes of the jury as does an explicit chart entry, and it is easily subject to challenge on the basis of recall: 'Yes, this ED visit was two years ago, and I see 25 patients in the ED every day; and no, I cannot recall this particular ED visit, but I am sure that I did X, Y and Z based on my usual and customary practice'. Sometimes the jury buys this and sometimes they do not.
  3. by   guestng82
    Quote from JustBeachyNurse
    That makes no sense. Where is the evidence the work was done a year later. The opposing counsel must have a field day with that logic. My sister is s prosecutor. You would lose in court against her if you presented blank documentation and claim it was done.
    Please see RiskManager's response to my comment right below yours. She explained it a LOT better than I can. I'm not that great with words.

    Basically, we do not use this defense often because our doctors are rarely deposed. But we do have instances where the documentation just doesn't exist, but our insured is adamant that they did it. So they are told to rely on the "just because it wasn't documented, doesn't mean it wasn't done."

    I've worked here for almost six years, and we've only gone to trial once and only had maybe four or five of our clients deposed. The trial was for a deceased doctor who left his assessment almost completely blank. It's not much to go on, but when you have nothing else, it's something at least.
  4. by   guestng82
    Quote from RiskManager
    Yes, this is the Plan B that we use when the charting is not done: we argue that it is our usual and customary practice to do X, Y or Z; we can think of no reason why we would not have followed our usual and customary practice in this instance; and therefore just because it is not charted does not mean it was not done.

    This is done to try and salvage a situation in which the charting is poor or non-existent. This line of argument does not carry near as much weight in the eyes of the jury as does an explicit chart entry, and it is easily subject to challenge on the basis of recall: 'Yes, this ED visit was two years ago, and I see 25 patients in the ED every day; and no, I cannot recall this particular ED visit, but I am sure that I did X, Y and Z based on my usual and customary practice'. Sometimes the jury buys this and sometimes they do not.
    Yes, thank you. You are way better at writing that than I am. All of our clients are coached to never say they don't remember something or didn't do something. They're told to always say what they would normally do in the situation if they did not remember the patient or the specific visit.

    It's amazing how many physicians we have who just don't write anything in their ER records. So many assessments are left blank, and on the rare occasion that they testify, what else can we do? They're not going to straight up admit that they didn't do anything so we have to rely on that they did do it, but they just didn't document it.
  5. by   CBlover
    Folks I have to tell y'all something interesting that just occurred that I think you'll be appalled by. I'm a new mom and a member of an online "new mom community" I guess you could call it. On it, we new moms post questions or concerns or just fun stuff regarding life with our new little one and we can respond or whatever. It's like AN but for moms. So a mom posted. The title was "HELP!!!" ...Ok. So. She was wondering why her kid screamed all the time. Went on to explain she was giving him only 1 scoop of the powdered formula to 9 oz of water! It's supposed to be 1 scoop to 2 oz of water!!!! She was basically giving him flavored water!!! So of course all the moms KINDLY told her why her kid was screaming hungry. She literally threatened the mothers who JUST ANSWERED her question and even called their babies vulgar names and all. After all she did ask for "HELP!!!" Needless to say the thread was closed thanks to her vulgarity. She was reported to agencies. But wow. So sad for that baby.
  6. by   RiskManager
    Quote from Midiosa
    Please see RiskManager's response to my comment right below yours. She explained it a LOT better than I can. I'm not that great with words.
    I actually self-identify as a 55 year old bald white male.
  7. by   guestng82
    Quote from RiskManager
    I actually self-identify as a 55 year old bald white male.
    Sorry about that!
  8. by   kristier
    That got to me as well-- it's the same color so it must be ok, right? I wasn't there so I am not going to judge whether its lack of education or lack of support or lack of supervision or just lack of basic instinctual caring on mom's part. But I agree, that really hurt to read.
  9. by   Mat4
    Quote from Ruger8mm
    My manager has commented on two occasions that my charting and documentation is to indepth and specific (very detailed). I just ignore her. There is no way I'm ended up in court and not being able defend myself or not remember what happened in that situation. My charting will save my butt.
    While I understand your thinking here, your manager has point. Your statement assumes you will never make a mistake, but if you do, you just hung yourself with your charting. Lawyers love this, and your detailed charting will provide them all the evidence they need, and they will use it against you. If you document in a little less detail it can provide you some wiggle room, and your attorney will be able to provide you a better defense. Remember "anything you say can and will be used against you in a court of law" applies not only in criminal proceedings but in civil as well. This just comes from my experience of working in a plaintiffs firm. I am not a lawyer.
  10. by   Mat4
    Quote from JustBeachyNurse
    That makes no sense. Where is the evidence the work was done a year later. The opposing counsel must have a field day with that logic. My sister is s prosecutor. You would lose in court against her if you presented blank documentation and claim it was done.
    the burden of proof is not on the defense. Many times the defense says very little and let's the plaintiffs case implode on itself.
  11. by   mrmtrn
    As an auditor, I review charts from facilites across the US. I am amazed at what is and isn't documented and I frequently have commented how in earth would some of the things I see stand up in court. Even with EMR, there will be pages of documents left blank or marked as "not assessed" so the clinician can get to the last entry field to chart on the patient with significant dementia "reminded patient to use call bell". It also important to realize that documentation is also used to support justification of billing, and definitely in that area, if it isn't documented, it didn't happen; and if it didn't happen it won't be reimbursed.
  12. by   1Buckeye
    That poor little baby!

    And, what happens when an RN DOESN'T document what she's done, the final records prove she did NOT document...and, the DON admits the RN didn't document it? The DON exact words: "It's just that it didn't get documented! We've discussed it with the RN." The procedure the RN didn't document (Which meant it didn't even get billed for.) caused catastrophic results, which ended the patients life.

    What do you do about those instances?
  13. by   Mat4
    Quote from 1Buckeye
    That poor little baby!

    And, what happens when an RN DOESN'T document what she's done, the final records prove she did NOT document...and, the DON admits the RN didn't document it? The DON exact words: "It's just that it didn't get documented! We've discussed it with the RN." The procedure the RN didn't document (Which meant it didn't even get billed for.) caused catastrophic results, which ended the patients life.

    What do you do about those instances?
    documentation for billing reasons v. documentation for "legal" reasons creates an interesting conundrum.

    I would assume during a dep. the attorney would explore the statement "we've discussed it with the RN"
    I also think that once the attorneys have a party admission, regarding the procedure being ordered, but not recorded, the focus would shift to "what caused the catastrophic results."

    Further I really don't think the DON's admission would hold any weight unless she was physically there.

    Coming from the legal field and going into the nursing field I find this all very interesting.

close