Taking a New Look at Your Documentation: A Case-Based Discussion to Avoid Litigation

In the United States, wound care is highly litigious, with 17,000 pressure injury lawsuits filed per year.¹ Medical malpractice cases have not decreased despite some tort reforms. The financial burden of litigation has also shifted to providers through larger liability insurance premiums and deductibles. 

All this means legal risks for wound care providers will never go away. Our session at SAWC Virtual offered several case examples of issues with patient documentation, showing what to include and what to avoid in medical records. 

What are the factors that increase the risk for medical malpractice as it relates to skin and wounds? Factors include an aging population and increased obesity.² Given that pressure injuries are a significant problem across the continuum of health care, practitioners are obliged to know their practice and terminology.³ 

Practitioners also need to know and avoid the problem areas in wound care documentation. To that end, documentation should be accurate, timely, true, complete and legible. Quality documentation is critical since the medical record describes the complete picture of medical care, the communication method, financial and regulatory aspects, and legal issues. 

To attain quality documentation, it is important to understand your electronic medical records (EMR) system. You should know how to amend, addend and append, and know how to use the narrative and comments in the EMR. Be conscious of spelling, grammar, and punctuation, as misplaced commas or apostrophes can change the meaning of a sentence. Watch chosen language. Be positive and objective, writing the note as if it is about a loved one, and documenting like the note will be read aloud in a deposition. In addition, make the note patient-centered and know the correct terminology. 

Some things to avoid in documentation include defensive charting, bad-mouthing patients and/or other providers, colorful adjectives, subjective opinions, and putting “incident report completed” in the note. 

For non-specialists, here are some tips to keep you on safer legal ground.³ 

•       Document intervention and responses

•       Change plan of care/treatments and document rationale

•       If needed, discuss “unavoidable” in patient record

•       If “red flag” seen, contact risk management (e.g., retained negative pressure wound therapy sponge, operating room (OR) skin damage)

•       Maintain liability insurance—make sure it covers state board practice action

 You can help your medical defense attorney by providing evidence-based care that is completely and well-documented. 

To access the SAWC Virtual session “Taking a New Look at Your Documentation: A Case-Based Discussion to Avoid Litigation,” click here.

Janice Beitz, PhD, RN, CS, CNOR, CWOCN-AP, CRNP, APNC, ANEF, FNAP, FAAN, is a Professor of Nursing and WOCNEP Director at the School of Nursing–Camden, Rutgers University in Cherry Hill, NJ.

Edward Beitz, JD, is a partner at White and Williams LLP in Philadelphia.

References

1. Agency for Healthcare Research and Quality (AHRQ). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html. Accessed March 30, 2020.

2. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. state-level prevalence of adult obesity and severe obesity. N Engl J Med. 2019;381(25):2440-2450.

3. Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers—a consensus paper from the International Expert Wound Care Advisory Panel. Adv Skin Wound Care. 2010;23(11):493-507.