Documentation of Obstetrical Emergencies · Obstetrical Emergencies Craig M. Harris and Mary Ashley...
Transcript of Documentation of Obstetrical Emergencies · Obstetrical Emergencies Craig M. Harris and Mary Ashley...
Documentation of Obstetrical EmergenciesCraig M. Harris and Mary Ashley Cain, M.D.9-17-2016
Objectives
Discuss OBGYN experience and litigation
Review Florida respondents experience with litigation
Identify how to improve litigation outcomes
Discuss the significance of EMR and documentation
OBGYN Experience
Litigation and Obgyn
2012 ACOG survey on professional liability
9,006 completed surveys
77.3% of OBGYN report being involved in at least one liability claim
Average 2.64 claims per Obgyn
42% reported claims arose during residency
51% changed practice due to cost of liability insurance
58% changed practice due to fear of litigation
Litigation and ObGyn
Top Ob allegationsNeurologically-impaired infant (28.8%)
Stillbirth/neonatal death (14.4%)
Delay/failure to diagnose (11.1%)
Top Gyn allegationsPatient injury -major (29.1%)
Delay in or failure to diagnose (22.1%)
Patient injury -minor (20.7%) (20.7%)
Florida Respondents
90.9% of respondents reported at least one liability claim
74.6% made changes to practice as a result of fear of claims
69.7% made changes as a result of availability/affordability of malpractice insurance
Florida respondents Fear of litigation
Stopped offering/performing VBAC 39.4%
Decreased number of high risk obstetric patients
37.1%
Increased number of cesarean deliveries 31.2%
Decreased number of total deliveries 14.9%
Stopped practicing obstetrics 9.5%
http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyDistrictFlorida.pdf
Obstetrical practice changes
Improving Litigation Outcomes
THE CHART IS YOUR BEST WITNESS
Strong DocumentationImproves patient care
May prevent a lawsuit from being filed
Easier to find expert support
Juries appreciate detail oriented physicians
Improves your testimony
Makes your deposition less stressful
Makes your lawyer’s job easier
Critical Points
Times
Risks and Benefits
All Conversations with Patients
All Conversations with Consultants
Details of maneuvers
Leaving Against Medical Advice
Do not to be critical of patient/staff/other physicians
Leaving against Medical Advice
• Patient leaving AMA
• Likely Litigious
• Use the standard form
• Ensure signature prior to leaving
• Hospital copy included in patients medical
Document conversation
specific risks of refusing care
Patient reasoning for leaving
Avoid dramatic discussions
•
EMRs
Do not become overly reliant on templates
Sometimes you will need to create your own note to include all relevant information
Be cautious in selecting from drop-down menus
Revisions and Addendums
Do not make substantive revisions to note
Especially weeks or months later
And/or when there is a bad outcome
Self Serving
Makes a good case for a plaintiff virtually unwinnable for the defense and gives some traction to a bad case for the plaintiffs.
Handling Bad Outcomes
Talk with the patient and family
Engage in active listening
Review the sequence of events
Provide facts
Document the conversation
Be available, do not disappear
Moving forward
Develop incident specific templatesACOG documentation guide for shoulder dystocia
http://www.acog.org/-/media/Patient-Safety-Checklists/psc006.pdf?dmc=1&ts=20150324T2004442213
Questions?
EMR and Documentation
• Review of closed claims in the Albert Einstein College of Medicine System o seven cases in which care was compromised due to a missing or
incomplete prenatal chart.
o Shoulder dystocia when delivering MD was unaware of ultrasound noting macrosomia
George and Bernstein, Current Opinion in Obstetrics and Gynecology 2009, 21:527–531
EMR and Documentation• 2005 qualitative and quantitative study of housestaff interaction
with computerized order entry
• Concluded electronic systems lead to 22 types of medication errors
o Fragmented displays
o Mistaken dosage guidelines
o Double dosing facilitated by separation of functions
o Inflexible ordering formats
o ¾ of participants witnessed these errors one or more times per week
Koppell et al. JAMA 2005. 293; 1196-1203.
EMR and Documentation
• 2005 Cross-sectional survey
o 263 physicians and 1614 clinical visits
o Clinical information reported missing 13.6% of visits
o 44% of missing information somewhat likely to adversely affect patient care
o Missing information less likely in settings with an EMR (OR, 0.40; 95% CI 0.17-0.94).
Smith et al. JAMA 2005 , 293: 565-571
EMR and Documentation
• 2005 Cross-sectional survey
o 263 physicians and 1614 clinical visits
o Clinical information reported missing 13.6% of visits
o 44% of missing information somewhat likely to adversely affect patient care
o Missing information less likely in settings with an EMR (OR, 0.40; 95% CI 0.17-0.94).
Smith et al. JAMA 2005 , 293: 565-571
EMR and Documentation
• 2005 Retrospective Serial Cross Sectional study
• Following implementation of EMR
o Office visits fell 9%. (P <0.0001)
o No change in use of laboratory and radiology services
o Increase in telephone consults
• Increased comfort with telephone due to availability of information.
Garrido et al. BMJ 2005 330: 581
References
Garrido et al. BMJ 2005 330: 581
George and Bernstein, Current Opinion in Obstetrics and Gynecology 2009, 21:527–531
http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyDistrictFlorida.pdf
Koppell et al. JAMA 2005. 293; 1196-1203
Smith et al. JAMA 2005 , 293: 565-571