Court Appearance and Importance of Documentation - page 3

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   Mat4
    Quote from 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.
    I see this everyday, people come into our office with all their "evidence" thinking it will hold up in court. What most people don't know is the rules of evidence, the thresholds to bring claims, each prong must be met and proven. So there are a lot of hurdles to be jumped. The fact that something isn't documented is not enough to prove negligence. It is probably enough to get you fired though. haha.

    If anyone wants to read more about this, look into the rules of evidence, torts, civil procedure. etc
  2. by   1Buckeye
    The procedure was never even ordered! The patient was my mom. Both my sister & I witnessed it. The RN laughed & said "We don't make very many friends when we do this", while our mom screamed out in horrific pain...went instantly semi-comatose & took her last breath 24 days later.
    There are massive cover-ups throughout Mom's records.

    What a nightmare it's been for us, but not near the horrific nightmare it was for Mom. We will never stop trying to get justice...not only for Mom, but all that have and will follow.

    You don't ever stop hearing the horrid screaming she went's there 24/7 365 days a year.
  3. 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.
    In my earlier comment, I meant to add that it's funny how in med mal cases, there's so much of the "if it wasn't charted, it wasn't done", but on the flip side, in our worker's compensation cases (where we represent the employers and insurance companies), we have so many employees who try to claim back, neck or shoulder pain so many months after a work accident. When there is no mention of this in the records, they claim that they told all of the physicians, nurses, etc. who assessed them, and the HCP's must have just forgotten to put it in the chart. It's amazing how many judges will allow that and render judgments in favor of the employees for these complaints.
  4. by   MicsterRN
    To 1Buckeye:
    For learning purposes, may I ask the procedure performed and in what clinical setting?
    I am so sorry for your loss and the disturbing memories.
  5. by   Surfandnurse
    General question: how often does an RN actually lose his or her license over malpractice?
  6. by   Rose_Queen
    Quote from Surfandnurse
    General question: how often does an RN actually lose his or her license over malpractice?
    If you look over the disciplinary actions from the BON, you will find that the vast majority of them are for either drugs or alcohol impairing practice. You can probably find a list of these actions on the BON website or via a newsletter. Here's a link to PA's most recent list.
  7. by   1Buckeye
    As difficult as this is to write about...sitting here feeling faint with a pounding heart...I do hope this will help at least one patient.

    It was a totally unnecessary foley cath. (Mom had just used the bedpan.)

    The nurse that did that to her has been for many years & still IS a CEN.

    The DON tried to convince my sister & I there WAS no foley used, that's why it didn't get documented. QUOTE: "Why would there have been a foley, when the records state she'd used the bedpan?!" So, I pointed out the fact that in the records, the straight cath used to get the urine sample was done AFTER Mom had used the bedpan...and the words: "Tolerated well" were absolutely FALSE! That hurt Mom so badly, she cried out: "OW,OW,OW! What are you DOING?!" I explained to her they needed a urine sample. That hurt her so badly, she got VERY quiet & vomited. ( The urine sample came back with moderate blood. ) Then, came the horrid foley!

    After Mom had used the bedpan, she even said: "Boy, what happened to me, this afternoon?!" I told her that maybe her bladder quit working for a little bit." (Mom had been making numerous trips to the bathroom and not doing anything...her abdomen was swelling and she got a splitting headache. She asked for my sister & I to call 911...we did!) In fact, the Chief Complaint on the ED records state: SEVERE HEADACHE

    I had just had Mom to the doc for a physical 2 days earlier & all of her tests (including urine tests) all came back normal.

    After they (DON & ED Supervisor, both female) "talked " with the CEN, they admitted there was a foley. I also got the hospital chain's headquarters to admit that, and I quote what was said to me: "Yes, it hurt & Yes, it made her bleed, but...she had dementia!"

    As for the cover-ups throughout Mom's records? Each x-ray & scan showed NO foley cath...NONE! (I even had them all read, again by 2 different independent radiologists.) Yet, there were continuing records of the foley, in the 3 days Mom was in the hospital. I can still hear her screams coming from the x-ray room, to this day. I "know" now why she was screaming so badly. They were removing and replacing that foley...just like the CEN did in the ED.

    Her white blood count soared while she was in the hospital for those 3 days...(TRIPLE of what they were 2 days earlier)... & not ONE antibiotic was given to her...not ONE! You couldn't lay a finger on her w/o her screaming out in pain. (THAT did get in her records.)

    A few months later, the Governor of the state appointed that CEN to a state board!!! I wrote him 2 letters explaining what had happened & all I got back were the signed green return receipt's...proof that his office had gotten them.

    We will NEVER give up trying to get justice for not only Mom, but...for every patient that has & will follow her.

    Elderly women, & especially those that have had children, can make it very difficult, if not impossible to get a foley in them. Their internal body parts can fuse together. I've learned more about foley insertion than I ever thought possible & I know more than some CEN's, for SURE!

    The hospice nurse told me Mom's foley was latex...Mom was allergic to latex!!!!!!!!!! Latex allergy is even on the EMS report. Mom wound up with Purple Bag Syndrome. The hospice nurse didn't know why the tube & bag were turning purple. I did a quick search on the web, found out what it was & told the hospice nurse. She'd never heard of it!!!

    It's a nightmare & I've got to quit writing about it...I can't see through the tears, anymore. Talk about a bad case of PTSD.

    This all happened on Mother's Day, 2013. Mom was a VERY healthy 86 year old.

    Thank you for caring!
  8. by   Steffy44
    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.
    How ironic this was just covered in this weeks reading for my BSN. The example used was those of us working who are supposed to chart by exception. If I check cap refill at 8 AM and nothing changes until 3 PM it doesn't mean I didn't check in just means it didn't change.