Responsible Documentation of Patient Care IV

Chain of Command

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Some of the most frequently requested documents from health care institutions in preparation for litigation are Policies & Procedures. An example: Pitocin dosage and management, nursing protocols, electronic fetal monitoring, VBAC, shoulder dystocia, mag and pre-e, preterm labor, oxygen administration and neonates, AND Chain of command. Plaintiffs’ attorneys will compare relevant policies and procedures to the care provided and how it was documented. Obviously, they are seeking discrepancies in care and how it was recorded. If, for good reason, you deviate from policy in a particular situation, document why. Carefully outline your reasons for departing from policy, who, if any, has been consulted, and who is supporting your actions, and the name of that provider.

Attorneys love Chain of Command (COC). They will closely examine an institution’s policy regarding COC in order to establish failure of duty to advocate for your patient in an emergency situation. Attorneys will address COC when exploring situations that differ from usual treatment plans. Again, when a situation requires a deviation from established plans, thoroughly document the reasons for doing so.

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Include a clear account of the content of conversations with colleagues and consultants. “Discussed with Dr. A” is not enough! You must document a detailed account of your discussion. Obtain familiarity with your institution’s policies and procedures regarding this process and ensure that your documentation is consistent with hospital policy should this situation ever arise.

In a case involving placental abruption and bad strip, the triage nurse, L&D nurse, residents, and attendings. None of these individuals was talking to each other. The plaintiffs’ attorney took advantage of this and chose the provider (nurse) upon whom to heap responsibility.

Deposition Excerpt

Atty: Who would you contact if going up the chain of command?

Nurse: I don’t know. The residents do that. That’s not me.

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Atty: Have you ever seen a written Chain of Command Policy at your hospital?

Nurse: Like the actual policy?

Atty: Yeah, the actual written policy.

Nurse: I don’t remember. I’m sure I have but I don’t remember.

Atty: If you had seen one, would it have been in your hospital orientation?

Nurse: If I’m thinking right, there is a policy – at one point, there was a policy hanging in the bathroom maybe. I don’t think it’s there anymore, on how to do that.

Atty: Would it be correct, though, that at least from what you’ve seen in the chart, you don’t see any evidence that chain of command was followed?

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Nurse: That would be correct. There’s no documentation that says that. That does not mean that it did not occur.

Atty: If it did occur, while you were taking care of the patient, do you think that you would have documented it?

Nurse: Not necessarily.

Atty: You would not have documented something this important?

Nurse: I don’t know if I would or not. It depends.

Atty: Who does your hospital’s policy for chain of command require you to contact?

Nurse: I don’t know.

Know your Chain of Command process and policy. In a legal case, you may be held liable for not taking the proper steps. Nursing care experts will testify that nurses have an independent duty as a patient advocate to go up the chain of command.

Not Documented – Not Done. 

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This is still assumed in the legal world. In addition, Poor documentation equals poor care. Lack of pertinent documentation = Fraudulent.

Factual and objective documentation is critical. Incomplete documentation is a frequently encountered error and it always interferes with the best defense of legal case. Obstetrical and neonatal providers encounter recurring clinical situations that account for fetal and neonatal injuries. The majority of the time fetal heart rate interpretation is an issue. Another issue is timely preparation for and intervention at the time of delivery, along with poor or absent intrauterine resuscitation effort in labor.

It is hard to explain that you acted appropriately when you didn’t document it. Claiming “habit and practice” won’t work, even though this is a frequent defense tactic. Most juries aren’t impressed. Expert witnesses for your defense are unable to support your care if there is no documentation of what you did.