Severe Consequences of Copy and Paste Documentation
This case study was put together by our partners at CRICO and was written by Jennifer Clair MacCready, CRICO Description A 40-year-old male suffered incontinence and partial quadriplegia attributed to improper management of a cervical hematoma, miscommunication, and substandard documentation among providers. Key Lessons Poor communication can lead to adverse outcomes Documentation in the medical record is intended to support decision making, reflect care provided during the patient encounter, and guide subsequent care If copying and pasting notes, ensure that pasted content accurately reflects the current assessment prior to filing Clinical Sequence A 40-year-old male with quadriparesis resulting from a...
Three new laws impacting the practice of medicine were recently passed by the Alaska State legislature. Importantly, these laws are expected to be signed by the Governor but are not yet effective at the time of writing this post. Senate Bill 91: Telehealth and Multidisciplinary Care Teams. This new law expands HB 265 that was passed in 2022. The changes now allow out-of-state physicians and multidisciplinary care team members to provide telehealth services when an Alaskan needs to receive ongoing treatment or follow-up care for a suspected or diagnosed life-threatening condition. Senate Bill 45: Direct Healthcare Agreements. This new...
As it is every year, numerous pieces of legislation impacting physicians were signed into law in California in 2023. The following new health laws are particularly relevant to physician practices and medical professional liability. This alert is based on information obtained from the California Medical Association. All laws are effective January 1, 2024, unless otherwise noted. Allied Health Professionals: AB 1070 – Supervision of Physician Assistants: Exceptions Permits a physician and surgeon to supervise up to 8 physician assistants at one time if all the physician assistants are focused solely on performing in-home health evaluations to gather patient information and...
Misinterpretation of CT Scan Delays Stroke Diagnosis
This case study was put together by our partners at CRICO and was written by Katherine Zigmont, Clinical Program Specialist Description A misinterpretation of a stat CT scan result and a lack of communication between providers delays an unresponsive woman’s stroke diagnosis. Clinical Events A 54-year-old female was brought to the emergency department (ED) in the late afternoon after being found unresponsive at work. The ED provider noted that the patient presented as lethargic, stuporous, and aphasic. A stat CT scan was performed, which the radiologist read as negative for a stroke. In the evening, the family asked for a...
MPL Defense Verdict Bolstered by Appropriate Consent Process
This case study was put together by our partners at CRICO and was written by Margaret Janes, Senior Program Director Patient Safety and Education Description Discussion with the patient about risks, benefits, and alternatives of a procedure helped in defense of a known surgical complication. Key Lessons Informed consent is a conversation with the patient that covers both what the patient may think is important and what the physician thinks is important Documentation in the medical record of discussions with the patient, beyond the informed consent form, will help support care provided in the event of an unexpected outcome Managing...