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4. Medical Malpractice and Medical Records.pptx

  1. 4. Medical Malpractice and Medical Records: Dr. Ayub Abdulkadir (Dr. Alto) Medical Ethics
  2. Malpractice: • Definition: • Malpractice is a preventable error in the care of patient resulting in harm to the patient. • Or Professional misconduct or demonstration of an unreasonable lack of skill with the result of injury, loss, or damage to the patient. • Malpractice acts consist of: 1. Professional misconduct. 2. Improper discharge of professional duties. 3. Failure to meet professional standards of care that result in harm to another person.
  3. • Negligence: unintentional action that occurs when a person performs or fails to perform an action that a reasonable person would or would not have committed in a similar situation. • Physicians and healthcare workers who fail to act reasonably in the same circumstances are negligent. •Medication errors are one of the leading types of medical errors.
  4. • For example, a surgeon is consulted to place a central line. He is very rude arrogant and speaks harshly to the patient. The patient signs consent after being informed of the complications and alternatives in management. A pneumothorax occurs and the patients is infuriated that this “high handed baster” hurt him. He files suit against the surgeon for malpractice. What will be the most likely outcome of the suit?
  5. • For example, a patient with diabetes has osteomyelitis on an X ray of his foot. The physician does not perform a bone biopsy and gives the patient oral cefadroxyl for six weeks. After therapy is over, the osteomyelitis has completely resolved. • The patient sees some literature on the Internet several months later conclusively showing that a bone biopsy is an indispensable part of osteomyelitis care to determine an organism and its sensitivities. In addition, he sees that intravenous therapy is the standard of care. He files suit against the physician. What will be the most likely outcome?
  6. The Tort of Negligence: • Malfeasance: performing a wrong or illegal act • Misfeasance: improperly performing an otherwise proper or lawful act • Nonfeasance: failure to perform a necessary action
  7. Four Ds of Negligence: 1. Duty: responsibility established by physician–patient relationship 2. Dereliction: neglect of duty 3. Direct or proximate cause: the last negligent act that contributed to a patient’s injury, without which the injury would not have resulted. 4. Damages: injuries caused by the defendant.
  8. Preponderance of Evidence: • One side must demonstrate a greater weight of evidence than the other side. • The plaintiff (patient) must prove that it is more likely than not that the defendant (physician), in this case the physician, has caused the injury. • If the defendant demonstrates more convincing evidence than does the plaintiff, then the case will be found for the defendant. • If both sides demonstrate equally convincing evidence, then the case will usually be found in favor of the defendant.
  9. Damage: • Damages refer to any injuries caused by the defendant. Patients seek recovery, or compensation, for a variety of damages: 1. Permanent physical disability. 2. Permanent mental disability. 3. Loss of enjoyment of life. 4. Personal injuries. 5. Past and future loss of earnings. 6. Medical and hospital expenses. 7. Pain and suffering.
  10. Types of damage: A. Compensatory damages: court-awarded payment to make up for loss of income or emotional pain and suffering. B. Punitive or exemplary damages: monetary award by court to person harmed in malicious and willful way; meant to punish offender. C. Nominal damages: slight or token payment awarded by court.
  11. Fraud: • Fraud: the deliberate misrepresentation or concealment of facts from another person for unlawful or unfair gain. • Fraud in healthcare includes a wide range of illegal actions. • Fraud in the healthcare setting is one of the fastest growing criminal areas.
  12. Defense to Malpractice Suits: • Affirmative defenses: • Denial = Plaintiff must prove defendant did wrongful or negligent act. • Assumption of risk = Prevents plaintiff from recovering damages if plaintiff voluntarily accepts a risk associated with the activity. • Contributory negligence = Conduct on part of plaintiff that contributes to cause of injuries. • Comparative negligence = Plaintiff’s own negligence helped cause injury.
  13. Malpractice Prevention: 1. General guidelines 2. Safety 3. Communication 4. Documentation
  14. Medical Records: • Medical records: is all of the written documentation relating to a patient. • The includes: 1. Past history information. 2. Current diagnosis and treatment. 3. Correspondence relating to the patient. • Billing information is often maintained in a separate accounting record.
  15. • It is important to remember that the medical record is a legal document. •Purpose of the Medical Record: 1. Record of patient from birth to death. 2. Document for continual management of patient’s health care. 3. Provides data and statistics. 4. Tracks ongoing patterns of patient’s health.
  16. A Medical Records Filing System
  17. Contents of the Medical Record: • Personal information about patient • Clinical data or information 1. Records of medical examinations 2. X-rays 3. Lab reports 4. Consent forms 5. Referrals: PT/OT 6. Prescriptions and refills
  18. Example of SOAP Charting
  19. Two Common Forms of Charting: • POMR: Problem-Oriented Medical Record includes chronological record of each visit • SOAP: subjective, objective, assessment, plan • Subjective statements of patient • Objective data such as lab reports, vital signs • Assessment or diagnosis • Plan of treatment.
  20. Corrections and Alterations: •Draw one line through error •Write correction above error •Date and initial change •Do not erase or use correction fluid •Falsification of medical record is grounds for criminal indictment.
  21. Example of Corrected Chart Notation
  22. Timeliness of Documentation: • Medical records must be accurate and timely • All entries must be made as care occurs or as soon as possible afterward • Should be completed by physician within 30 days following patient's discharge from hospital.
  23. Confidentiality: • Medical records should not be released to a third party without patient’s written consent • Only specific records requested should be copied and sent • Taking photos or other visual images of patient without consent is invasion of patient’s privacy.
  24. Ownership : • Physicians or owners of health care facility own the medical record • Patients have legal right of “privileged communication” and access to records. • Patients must authorize release of records in writing • Doctrine of professional discretion: physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record.
  25. Release of Information: • Never send entire medical chart unless it is requested • Do not send original • Record may not be released to patient without physician’s permission • Patient must sign release form for information to be sent to insurance company.
  26. Retention and Storage of Medical Records: • Each country varies on length of time records must be kept • Legally, records must be stored for a minimum of ten years from time of last entry • Minor’s records must be kept until patient reaches age of maturity.
  27. Storage: • Current records usually kept within physician's office • May rent storage space • May be placed on microfilm • Kept in fire-proof, locked area.
  28. Medical Records Storage Unit
  29. Computerized Medical Records: • Data on patient records can be created, modified, authenticated, stored, and retrieved by computer • Special safety measures should be taken to establish personal identification and user verification codes for access to records • Should be accessed on need-to-know basis.
  30. Use of Medical Record in Court: • Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization • Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena.