Presented by: Chamiza Pacheco de Alas, Esq.

1
Mitigating Medical Malpractice Risks Through
DocumentationAtty Work Product Confidential

• Presented by Chamiza Pacheco de Alas, Esq.
• Associate University Counsel
• UNMHSC Office of the University Counsel

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Med Mal Claims and Lawsuits Process Overview at
UNM Health System

• Tort Claim Notice Received within 90 days of
  alleged injury
• Litigation Hold Email goes out requesting
  preservation and production of documents NOT in
  medical record. This is a legal evidentiary
  requirement, does not mean you are being
  named/sued/targeted, etc.
• Certification and documents returned within two
  weeks.
• Key providers (people we think have best/most
  information) interviewed.
• Decision made to recommend settle, deny or sit
  on it to State RMD, hopefully within 90 days.
• Subsequent lawsuit may be filed within 2 years of
  incident (for adults)

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Communication Best Practices

• Need an effective way for patients/family members
  to reach team (and eventually attending) at any
  time.
• Need a specific time frame established for seeing
  patients who are new admitted, critically ill, or
  experiencing significant changes.
• Sit at eye level with patients when
  communicating.
• Use active listening.
• Ask patients to repeat back what you have said.
• Treat patients concerns seriously.
• Encourage family involvement.

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Best Practices for Consultations

• Try to avoid curbside consultations that go
  beyond questions aimed at the general education
  of the requesting physician. (i.e.no questions
  about specific tests or studies, record review
  would be best practice, diagnosis confirmation is
  requested).
• Document when a consult is requested in the
  record, and when it is received (if possible).
  Important to get accurate timelines in the
  record. If consult is refused, document that and
  the stated reasons. Consultants should be doing
  parallel documentation.

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Best Practices For Documentation

• Medical Records tells the story of the patients
  care and should do so accurately and
  meaningfully.
• DO NOT cut and paste (particularly from medical
  student notes, usually by residents)it is very
  obvious. Check notes before you co-sign for
  cutting and pasting. Be particularly mindful in
  cases with conflict or difficult social
  situations.
• If you disagree with something a medical student
  or resident has stated relating to patient care,
  document in an addenda or new note.
• Note times where relevant .
• Use a neutral tone in documentation, particularly
  where there are conflicts between servicesjust
  the facts.
• Medical record is not confidential or privileged,
  do not put things that should be confidential and
  privileged, such as advice from Office of the
  University Counsel, in the medical record.
• Be careful about how you document advice received
  from non clinical entities (i.e. risk
  management)at times that advice is misstated
  putting the institution in a bad situation.

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Mock case What should be in the note and how
(from a medical-legal perspective)?

• Mary Lamb, 72, came into the E.D. at 1AM
  complaining of chest pain, shortness of breath,
  and trouble sleeping. She stated she spent the
  day chasing sheep. The E.D. paged Dr. Smith, a
  resident, at 4AM asking for a consult regarding
  admission. Dr. Smith saw the patient at 6AM.
  Cardiology had been consulted by the E.D. but had
  not yet seen the patient when the resident saw
  him. Mary Lamb has a history of falls and
  reports she has been told she has some sort of
  blood clot problem. She doesnt believe it.
  She reports taking a variety of homeopathic
  medications but cant remember them all. She is
  requesting to go home because she is tired of
  waiting and the gurney in the E.D. is
  uncomfortable.

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Mock Case Documenting Social Issues

• Miles McQueen is a 19 year old developmentally
  disabled man being cared for by his parents, who
  are divorced. There is no documented power of
  attorney. There has been no formal assessment of
  his capacity. He has been admitted to your
  service due to his uncontrolled diabetes. You
  have instructed both parents that he must be on a
  very strict diet and insulin management regime.
  Nursing reports to you that his mother was seen
  feeding him ho hos at lunch, and then giving him
  insulin she brought from home. When confronted
  by nursing she stated that the insulin fixed the
  sugar from the ho hos. When you spoke to her
  and told her she had to stop feeding him food
  from home and dispensing insulin she stated hes
  my kid, I get to decide what happens to him in
  here. You become concerned and call legal, you
  are advised to formally evaluate capacity and to
  consider an APS referral. You page psychiatry
  and are told they cannot do a capacity evaluation
  without knowing what the decision is they are
  evaluating his capacity in reference to. Later
  that night, you receive a report from nursing
  that the mother was feeding her son an in ice
  cream sundae and when confronted by nursing staff
  replied fk off, hes my kid, Ill do whatever
  I want. Im taking him home in the morning
  Nursing stated they and her son were both
  fearful. Additionally, they smelled alcohol on
  her breath. The next morning, you call Adult
  Protective Services. They state they wont be
  investigating as he is in a safe place. What do
  you document? How?

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Example of good social documentation

• ID 3 wk PHM presented with acute L humerus fx,
  admitted for NAT. Currently on medical hold.
• 24 hr events
• Pt remained clinically stable overnight
• Pediatrics, CART and CYFD had prolonged
  discussion with multiple CYFD officers regarding
  their original assessment of returning patient to
  parents under supervision of a safety monitor.
  CYFD persisted in adhering to their initial plan.
  Pediatrics placed medical hold on patient. APD
  contacted. CYFD revised discharged plan and
  required the father to leave the home premises
  prior to pt returning home. Father cannot be
  alone with pt. without supervision.

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Discussion/Questions?