Legal Check-UpYou might feel a slight pinch….

M. Meghan KiefferAssociate Counsel

Loyola University Health System

July 24, 2013

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One Rule of the Day…

Please don’t shoot the messenger!

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Departments You Should Know

General Counsel (6-1600)Lawyers to the Corporations

Risk Management (6-4215)Practical Solutions, Education

Claims Management (6-8150)Malpractice Case Defense

Organizational Integrity (6-2036)Ethical Legal, Regulatory Compliance

Graduate Medical Education (7-4463)Your Advocate

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Insurance

IndemnityYou, for “occurrence” coverage

DefenseJoint representation of all Loyola defendants

CounselDeposition Assistance

Hines VA

IDPR

When in doubt, call 6-1600

Venzke protects you:

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Legal Elements of Malpractice Case

Duty

Breach of Duty

Proximate Cause

Injury or Damages

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Standard of Care

What a reasonably well qualified physician

Practicing in the same or similar locale

Would do under the same or similar circumstances

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Proof of Malpractice(Deviation from Standard of Care)

Hired “expert”Testimony of co-defendants or their “experts”Your testimony

Direct admission (“always,” “never”)The parallel universe

The medical recordEspecially passive-aggressive, defensive, stupid

“Authoritative” texts/articlesAngry letters

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The Medical Record

PurposeMust reflect thought process

Absence of analysis jeopardizes conclusion

Wrong conclusion may be defensible with analysis but it never is without

EMR (EPIC)Cut & paste with care

No “texting” in our medical record

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Communication & Documentation

Communication is essential between care givers so that information about the patient is available to all those involved in the patient’s care.

Documentation in the medical record is one of those forms of communication.

Accurate Should demonstrate:

Complete Continuity of Care

Factual Proper and Approved Abbreviations

Truthful

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Medical Record Management

Primary purpose of the MR is to document the course of a patient’s health, history of illnesses, record of treatment received.

It is where the planning, coordinating, implementing and evaluating the patient care can be found.

It is the means of communicating with other members of the health care team caring for the patient in the past, now and the future.

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Does your Documentation Say What You Mean & How is it Interpreted?

The patient reports that since her colonoscopy, she has noticed some problems with her short term memory.

The patient fell while rollerblading on his left hand.

About 8 am this morning was the last time she had an inhalation. It is where the planning, coordinating, implementing and evaluating the patient care can be found.

She was the belted driver in the backseat.

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Does your Documentation Say What You Mean & How is it Interpreted?

He also has external hemorrhoids, which he says he likes to keep to himself.

The patient reports a fatal reaction to IODINE in the past.

Husband is somewhat negative and difficult to live with. She is not interested in a trial of medication for this.

Fracture to the proximal phalanx of the right fourth toe on the right fifth foot

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Does your Documentation Say What You Mean & How is it Interpreted?

She smokes one glass of alcohol per week.

Elderly male, seeking physician with hearing deficit.

The patient left the hospital feeling better except for her original complaint.

She is not clear on why she has seen me in the past, but states that whatever I treated her for had cleared up with whatever treatment I had given her. ???????????????

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Questions?

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The only real mistake is the one from which we learn nothing.

John Powell

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