Question

Please help with this...issues such as chart deficiecies, chart completion, etc? Thanks!

Alteration of Patient Record : A patient was admitted to the hospital's ambulatory surgery unit for surgical removal of four impacted wisdorm teeth. As required, a staff internist did ahistory and physical H&Pl examination prior to admission. The dental surgeon removed the wisdom teeth and administered penicillin intramuscularly as a prophylactic. The patient : had an immediate and violent reaction to the penicillin. After an extensive stay in the intensive care unit tCU the patient was discharged 0n routine discharge analysis, the health information anagement IHI clerk found several deficiencies requiring physictan completion. During this analysis of the record, the clerk observed that the H&P stated known allergies. As she was filing the ambulatory surgery record in the patient's file folder, she noticed that the previous encounter had ALLERGIC TO PENICILLIN stamped in red letters on the visit's cover sheet. She placed the record in the incomplete chart area for completion. When reanalyzing the chart a few days later, she saw that the H&P had been altered to read patient any drug allergies. While no one saw the alteration being made, the chart had been pulled for the dental surgeon. She took the record to the HIM director, who called the hospital attorney. The patient filed malpractice suit a few months later 1, Identily the issues involved in this situation sdi 2. Recommend a process to be implemented to prevent this problem from happening again

Answer 1

1. Issues involved

Malpractice :

Medical malpractice arises when a hospital, doctor or another healthcare professional, causes an injury to a patient by a negligent act or omission. The negligence can occur as a result of errors in diagnosis, treatment, aftercare or health management.

The malpractice suite is valid as the patient experienced severe anaphylaxis from penicillin and as per the physical history and examination (H&P), there are no known allergies. The anaphylaxis situation has to be avoided from proper H&P and a test dose before the injection.

Negligence: Negligence from the part of staff internist is evident, which lead to the malpractice suit.

Incomplete and inaccurate charting: Incomplete H&P resulted in all the consequences.

Inaccurate information and improper history collection. Information collected from the patient was inaccurate. The medical records checked after the patient discharge revealed that many areas require physician completion. Medical records could have been completed timely.

Alteration of records: After late completion, the records were altered, this will lead to malpractice suits. Changing the evidence is an added crime.

The five principles of documentation of medical records; accuracy, relevance, completeness, timeliness, confidentiality are not maintained properly.

2. Recommendations to prevent similar cases in future

• Follow the principles of medical record documentation.
• Any addition to the chart must be made as a “late entry”.
• The appropriate medical record attempts to be objective about what occurred and its timing.
• Enter Time and Date the entries in the record.
• While reconstructing what happened chronicity is very important.

• Include significant positives and negatives from the patient’s H&P.
• Avoid illegible recording.
• Provide proper training to the staff in medical records documentation and develop an institutional policy to follow.
• Follow formats like SOAP (Subjective, Objective, Assessment, Plan) or New SOOOAAP formats (S O O O A AP -Subjective, Objective, Opinion, Options, Advice, Agreed Plan)