Post on 17-Feb-2022
Documentationandotherlegalconsiderationsinhealthcaresettings
MidwiferyandMaternal&ChildHealthConference30July2016KarenCusackCorporateCounsel,TheRoyalWomen’sHospital
Introduction
Accountability
Whatis‘accountability’?• moralandlegalrequirements• responsibilityforownactions• answerabletoahigherauthority
Accountability
Sourcesofaccountability:• HealthPractitionerRegulationNationalLaw(Victoria)Act2009
• Commonlaw• EmploymentContract
Accountability
Sourcesofaccountabilitycontd:• PolicyandProcedureManuals,Guidelines,Practice• ScopeofPractice
– Lawfulness– Policy– Practice– Competency– Education– Knowledge– Qualifications– Accountability– Responsibility
Accountability
Howdoesaccountabilityplayoutinthelegalarena?• Coroner’sCourt• Civilactionfordamages• Criminalprosecution• NursingandMidwiferyBoard• VCAT
Accountability
YOUAREACCOUNTABLE• Goodpractice• Gooddocumentation• Followdirections,policies,proceduresandlegalduties
Documentation
• Authenticity• accurate• dateandtime• nameand signature• designation
• Timeliness• Contemporaneous
• Legibility• Goodforlegalreasonsandappropriatepatientcare
Documentation
Mainissues:• Litigationmaytakeyears• Memoriesarefallible– Patients/familiesmemoriesarenotasfallible
• Themedicalrecordwillusuallybetheonlyrecordofanevent.
Documentation
• e.g.Schedule8Drugs• s32 requiresrecordingof:
• detailsoftheSchedule8drug;• quantities;and• anyotherprescribedparticulars
• MustberecordedbyPRINTINGorWRITINGINALEGIBLEFORM–s32(2)
• Penalty– 60penaltyunits(approximately$9,500)
Documentation
NONOTESorINTENTIONALLYINCORRECTNOTES– NODEFENCE!
• beingtoobusytodocumentortofollowapolicyoraprocedureisneveradefence;
• noriswritingsomethingthatisknowntobeincorrect.
CaseStudy1
CaseStudy1- Facts:• patienta48yr oldmanwhowasadmittedtoaclinicwhichwaspartofthepracticeofaregisteredpsychologistfor‘rapidopiatedetoxification’
• theRODoccurredover24hoursduringwhichtimearegisterednursewascaringforthepatient
• followingRODthepatientwasreturnedtohishome
• Thepatientbecameunwellandwasadmittedtotheemergencydepartmentandsubsequentlydied
CaseStudy1
ComplaintallegedthattheNurse:• Failedtocarryoutobservationsofwithdrawalscale,temperature,
pulse,bloodpressureandrespiratoryrateatappropriateintervalsonPatientAincontraventionoftheClinicpolicy
• OR,iftheNursedidcarryoutobservationsthenhefailedtorecordobservationsofwithdrawalscale,temperature,pulse,bloodpressureandrespiratoryrateatappropriateintervalsonPatientAincontraventionoftheClinicpolicy
• Failedtoappropriatelymaintainthefluidbalancerecordoverthecourseofthepatient’sadmissionattheClinic.
• Failedtomaintainanadequatestandardofdocumentationontheobservationchartorinthenursingnotesinthepatientrecord.
• Failedtorecordtimeanddateofmedicationadministrationonthemedicationchart
CaseStudy1
Nursing&MidwiferyProfessionalStandardsHearing:• Admissionsmadethatheconsideredthathehadmadeseriouserrorswhilecaringforthepatient;
• Deepregretrepatient’sdeathandthecomplaintprocess.
CaseStudy1
Ordersmade:• Registrationlapsed,but• Ifreappliesmustcomplywithvariousordersandconditionsimposedincluding:• Supervision,educationandrestrictionsontheareaofpractice(i.e.notpracticenursingintheareasofDrugandAlcoholormentalhealth,oranyotherareawhichisnotconsideredtobeinhisscopeofpractice,educationorexperiencebythesupervisor)
CaseStudy2
CaseStudy2- Facts:• Patienta70yr oldmanwhounderwentalaparoscopic
cholecystectomy• transferredtothe‘ExtendedDayOnly’unitandhadbeen
experiencingpain.• assessedbyadoctorandanordermadeforincreasedanalgesia
(15mgmorphine).• thenextmorningthepatient’stemperaturewas38degrees,
heartrate120bpm andsystolicBPhaddroppedto80mmhg.Amedicalemergencyteamcallwasmadeandthepatienttakenbacktotheatrewhereaperforatedbowelidentified.
• duringthenightshifttheRespondentwastheonlymemberofstaffrosteredtoworkintheEDOunitandwasresponsibleforthecareofPatient.
CaseStudy2
Particularsofthecomplaintthat,duringthenightshift,theRespondent:1. Failedto:
a.performand/orb.documentacompletenursingassessmentofthe
Patient;2. FailedtoarrangeforthePatienttobereviewedbyamedicalofficerat2400hrs whenthepatienthadatemperatureof39degreesandapulserateof126bpm.
CaseStudy2
3. FailedtomonitorthePatient’stemperature,pulseandbloodpressurebetween2400hrs and0600hrs,or4. IftheRespondentdidmonitorthePatient’stemperature,pulse,bloodpressurebetween2400hrsand0600hrs she:a. failedtodocumentherobservationsinthePatient’smedicalrecord.b. failedtorecogniseand/oractuponanydeteriorationinthePatient’scondition.
CaseStudy2
5.InregardstotheadministeringofMorphine15mgs/cat0040hrs theRespondentfailedto:
a.i. conductand/orii. documentanursingassessmentpriorto
administeringthemorphine,toascertainthereasonforthePatient’spain.
b. documentinthePatient’smedicalrecordtheadministeringofthemorphine.
CaseStudy2
TribunalFindings:• Itisthefailuretorecordsomanyobservationsthatplacesthisconductsignificantlybelowtheexpectedstandard.
CaseStudy2
Orders:• formalreprimand• conditionsplacedonregistrationincluding:
• Toundergospecificnursingcourses• TonotifyhercurrentandanysubsequentemployeroftheTribunal’sfindings
Summary
DOCUMENT,DOCUMENT,DOCUMENT!
Anyquestions?
Karen CusackCorporate Counsel
karen.cusack@thewomens.org.au