If you began your Midwifery journey in Nursing School, you are familiar with documentation; paper and electronic. Although medical, nursing, and midwifery documentation was strictly paper for many decades, the current recording of patient care is with the electronic record aka EMR.

Documentation of care is an overwhelming subject but it’s importance, and role in malpractice litigation, cannot be over-emphasized. Naturally, insurance information, billing, patient care, and other important information, is processed through the electronic record. The focus of these next articles, however, is to outline how patient records can become important evidence in medical/nursing/midwifery-legal cases. Errors in medical record documentation fuel legal liability lawsuits. Inaccurate, incomplete, and incompetent documentation increases your chance of being involved in a medical negligence lawsuit. You may find yourself involved, anyway, despite perfect documentation, but you stand a better chance of being dismissed.

The following articles are narrowed down to issues that I have experienced most often in medical malpractice cases. I have worked both sides of these cases which I believe gives me a fairly broad perspective. I understand that you have faced documentation lectures, dealt with it on exams, and have probably developed nervous eyelid twitching every time the word is mentioned. But, I am hoping that I can impart some wisdom and novel information that may keep you out of the courtroom.

Medical Malpractice - Perinatal/Neonatal Care - Data Entry

The crowning jewel of medical malpractice is the “bad baby” case. Care in these specialties is multi-dimensional, which you already know. It is complicated and much is at stake in regard to maternal and infant care. Perinatal care is the only specialty which involves the well-being of two patients; more if you have infant multiples.

When things go wrong, outcomes may be tragic. Your professional documentation reflects your education, knowledge, competence and sound decision-making. Regret and tearful testimony will not mitigate incompetent documentation. Please internalize this: documentation errors drive patients’ lawsuits. Only you control the facts and evidence for or against you. Reducing your risk of involvement in litigation is your choice, every time you log in to document.

Initial steps in litigation, for both sides, plaintiff and defense, involves reviewing the electronic record in detail. Poor documentation and associated risk are two sides of the same coin. Terrible documentation in the medical record will boost the plaintiffs’ case and complicate your defense. Astute plaintiffs’ attorneys will emphasize that poor documentation not only reflects negatively on you, but interferes with team communication and responsible care. Which may lead to medical-legal inquiry.

At the time of filing a negligence lawsuit, the majority of facts and evidence has already been generated. By you. In the record. Poor and absent documentation of pertinent facts, especially in critical situations, WILL be used against you. Gaps and incoherence make determining rationale for your care difficult. Experts for your defense will look to your documentation and will either support or decline to support that your care fell within acceptable professional standards.

*Before going on, I must acknowledge the difficulty-bordering-on-impossibility of caring for critical patients and carving out the time necessary to document everything that is expected in the electronic record. Hospital corporations are absolutely culpable for record error and information gaps due to the demands made on care-givers, particularly the infinity of drop-downs, coding and the endless variety of minutiae that is required in determining provider metrics and other non-patient care information. There is rarely adequate time to do it all.

Documentation-Duty-Experience

A jury will be reminded that responsible documentation isn’t just about defending care providers. The most important issues at stake are the well-being of patients, mothers, and babies. Expert witnesses for EMR and the medical record will examine your documentation, word-for-word. Documentation evidence in the courtroom: good, bad, or ugly will likely be projected on a large screen, highlighted in yellow, underlined in every color of the rainbow, figuratively set on fire, and presented for the jury to see. You can be the most competent provider in the world but if your decision-making and subsequent documentation is deficient or incompetent, you are what you document.

As a responsible provider of maternal health care, it is your duty to provide competent care. Along with this is your duty to carefully document the care that you have provided. Competent documentation shows lawyers, judges, and juries that you acknowledged/understood your duty, accepted your responsibility, and were accountable to your patients and your profession.

The age and experience of the health care provider may also influence the way health information is recorded in the EMR. Unfortunately, veteran nurses and midwives seeking positions in corporate health care may find their ‘past experience’ detrimental to successful documentation in the electronic record . Unenlightened commentary suggests that exceptionally experienced providers experience difficulty when transitioning from handwriting their notes to typing their information. This attitude can even prevent experienced providers from being hired in corporate health care. The logic is straightforward – those who know how to type effectively are going to put more information in a narrative in a shorter amount of time than one who does not know how to type. People who do not know how to type (older nurses, doctors, or midwives) may avoid free-text narratives altogether because the change is too overwhelming. 1

Younger providers, accustomed to texting from their phones may also be inclined to use texting abbreviations in the narratives, as well. For veteran health care providers, not accustomed to texting, these types of abbreviations pose a significant problem. Text abbreviations can be mistakenly identified as medical abbreviations or the use of the text abbreviations may confuse or mislead someone relying on the information. Fluency in typing or texting makes a difference in how a patient’s information is charted in the era of electronic medical records. The greater confidence in one’s ability to type increases the amount of information in a chart but, at the same time, an over-reliance on texting, and the mistaken belief that all clinicians know basic text abbreviations, can lead to confusing patient notations.2

1. Electronic Medical Records and Litigation. 2018 Edition. By Matthew P. Keris. Thomson Reuters.§1-4, page 6.

2. Ibid at § 1:4.

https://www.midwivesontrial.com

Part II: to follow

Responsible Documentation Of Patient Care: Avoiding Legal Risk: Part I

Common Legal Claims Against Midwives, Part II