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Failure to Document Disruptive Patient Behavior

June 12, 2023

When a malpractice lawsuit is filed, lack of documentation can significantly complicate the process of proving the patient’s treatment met the standard of care and did not cause the patient’s injury. In the following case, the emergency department (ED) physician failed to adequately document three different aspects of the patient’s care: her disruptive behavior, her departure from the ED against medical advice (AMA), and her follow-up telephone conversation. Each failure complicated the defense of the ED physician’s case.

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Filed under: Practice Manager, Physician, Patient Care, Advanced Practice Professional, Documentation

Patient Safety and Liability Risks Associated with Texting in Healthcare: Case Studies and Best Practices

May 19, 2023

Text messaging has changed the way we communicate with each other. Like most people, healthcare team members use their mobile devices at work,1,2,3 and texting about patients is common.4 Texting with patients and other members of the healthcare team has risks and benefits.

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Filed under: Digital Health, Patient Communication, Article, Practice Manager, Physician, Patient Care, Documentation, culture of safety

Unprofessional Text Messages Complicated Defensibility of a Malpractice Claim

May 19, 2023

The medical record is not the forum for blame, personal attacks, or finger pointing.1 Text messages relating to patient care should be considered part of the medical record (whether they are transferred to it or not), and the same rule about appropriateness of forum should apply. If something about patient care is important enough to be texted, it should be included in the medical record. If it is something that does not belong in the medical record, then it should not be texted. It seems clear that the members of the healthcare team texting each other in the following case study did not expect their text messages to be used against them in the malpractice lawsuit.

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Filed under: Digital Health, Case Study, Practice Manager, Physician, Patient Care, Documentation, culture of safety

Contradictory Text Messages Contributed to Patient Misinterpretation of Care Instructions

May 19, 2023

Texting presents unique communication challenges. The brevity and casual nature of text communication that makes it convenient can also make it inappropriate in a healthcare setting. One key to using text messaging in healthcare is to know when an in-person or telephone conversation is necessary. Telephone conversations allow for important information to be exchanged with greater ease, and a more natural opportunity for questions and responses.

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Filed under: Digital Health, Patient Communication, Case Study, Physician, Patient Care, Documentation, culture of safety

Poor Documentation of Text Messages Complicated Defense of a Malpractice Claim

May 19, 2023

Text messaging can provide quick, efficient communication between physicians and patients. In malpractice litigation, it can also prove physician attentiveness and responsiveness. However, text messages can complicate the defense of a malpractice claim, particularly if they are not integrated into the patient record. Consider how documentation issues unnecessarily complicated the defense in the following case.

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Filed under: Digital Health, Patient Communication, Case Study, Physician, Patient Care, Documentation, culture of safety

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