Yes, accurate charting really does matter

by • January 1, 2009 • UncategorizedComments Off on Yes, accurate charting really does matter1333

© 2009 The Medical-Legal News 

• The Gist: Many medical cases are made or broken on fraudulent, incomplete or inaccurate documentation.
—RC

The November 2008 issue of the Legal Eagle Eye Newsletter (www.nursinglaw.com) carried two stories that highlight the importance of proper charting.
• In an Arkansas case a home-health hospice nurse charted a patient’s conditions before actually visiting the patient. The nurse was fired for falsifying the records. As a defense, the nurse claimed the patient’s status would have been the same whether or not the patient was actually visited. The court decided this was not the point and that intentional falsification was grounds for dismissal.
• In a Connecticut case a nurse overdosed a patient by administering too much Dilaudin. Realizing the mistake, the nurse then created a bogus verbal order from a doctor as a cover-up. The doctor was not the patient’s physician, however, and had never given such an order. The creation of the fake order was a criminal act, but did not relieve the hospital from its civil liability, according to the story.
• In the October issue of the Newsletter, a case was reported where a defendant hospital triumphed in a suit where the family of a decedent said the hospital had failed to diagnose the decedent’s heart trouble. The decedent had come into an ER for fluid replacement, not heart trouble. The charting did not indicate any complaints of chest pain, and no family member could corroborate any complaints of chest pain.

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