Nursing homes are affected by many challenges, many of which directly affect the quality of care and allegations of nursing home negligence. The challenges were highlighted by speakers at Preventing and Defending Long Term Care Litigation at The Conrad in Miami. Pat Iyer moderated a panel of defense and plaintiff attorneys and another legal nurse consultant.
What are the most common medical record deficiencies?
Legal nurse consultants may encounter medical record deficiencies that significantly impact the credibility of these documents. These are issues that arise in not only nursing home cases but also other medical malpractice cases. How many of these have you found?
- Failure to document physician notification of significant change
- Failure to record blood sugar prior to administering medication
- Significant gaps in nurses’ notes
- Failure to record blood pressure or pulse prior to administering medication
- Medications not started or timely discontinued
- Failure to document follow up with physician after leaving messages
- Documenting on the medical record after the resident is out of the facility
- Cut and paste documentation
- Missing records
- Altered records
- Block charting
- Discrepancies between different sections in the medical record
- Significant gaps in medication records, treatment records, and or activities of daily living records
- Late entries
- Unsigned notes or orders
Legal nurse consultants must notify the attorney handling the case when these medical record deficiencies are evident. The attorney may need to change strategies based on these issues. Your detail oriented inspection of records can make the difference in a case. Be sure to share your concerns when you see these problems.
Pat Iyer is president of Patricia Iyer Associates Inc. and the editor of Nursing Home Litigation, Investigation and Case Preparation. She edited Nursing Documentation, Fourth Edition. This material is based on the slides of John Wade, Esq., Brunini, Grantham, Grower and Hewes and Bradley Kelly, Esq., of Quintairos, Prieto, Wood and Boyer.