Summary: NY: missing signature on discharge summary: does this mean no instructions were given?
Information: DeLorenzo v. St.Clare’s Hospital of Schenectady, 2010-00433 (1/21/2010) –NY
Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe, ethically sound nursing practice. Thank You.
A glance into the ER waiting room reinforces your hunch that this storm has not yet subsided. There are no places to sit, patients lie on stretchers in the hallway, and there are more people signing in at the triage desk. Your hospital is situated just a couple miles up the road from the professional car racing facility and each year NASCAR related events seem to bring with them a nonstop flood of patients, rivaling those commonly seen during the holiday season. You sigh in exasperation, realizing that its only day two of the racing festivities and several more of these busy shifts are still on the horizon. At this moment you are waiting for two of your patients to look over their discharge instructions and prescriptions, sign their papers, and get dressed so that you can send them on their way and alert your charge nurse that the rooms are available. Making your way back into each room you find the the patients are seated and waiting for the “OK” to leave the ER. You bid each one well, advising them to drive safe, and collect your copy of the discharge instructions before signaling to the housekeeper that the room is ready to be turned over. On the way back to your seat at the nurse’s station you toss the discharge instructions into the Unit Secretary’s basket for processing, and search for your coffee mug. It’s way past time for a refill, and there are still six hours left to the night……
The Real Thing
Jane DeLorenzo presented to New York’s St. Clare’s Hospital on October 14, 2004 to be treated for dog bites to her wrist and thigh. After being evaluated and having her wounds attended to, she was discharged from the Emergency Room with aftercare instructions. Jane presented once more for treatment the following day, concerned about worsening pain and red streaks that had appeared at the area of her wounds to the wrist, extending up the arm. An abscess was discovered on one of the wounds so Jane was admitted to the hospital for further treatment to remove it. She would later file a lawsuit against the hospital for what she described as poor medical treatment and faulty discharge instructions provided to her by the Emergency Room Nurse—during the discovery phase of the proceedings it was noted that Jane had not signed the discharge instructions given to her by the ER nurse which raised the question of whether she had received them at all.
Questions for Consideration
- What are some actions the nurse could have taken to prove discharge instructions had indeed been provided?
- How would you have documented the discharge encounter with this patient? Why?
- Discuss some objectives and elements of nursing documentation. Provide your rationale.
- What are some discharge teaching guidelines for nurses? Provide your rationale.
There are two main reasons we nurses chart what we do about patients—to communicate with members of the healthcare team and to protect ourselves from as much liability as possible while in the process of caregiving. This article is for you newly minted nurses out there who may still be under the impression that “you’re covered” under the wing of whatever corporate entity that you are working for. If a patient and/or family brings suit against a hospital (and thus everyone involved with the care of a patient) don’t expect for your defense to be a priority or for the hospital to be concerned with protecting you, your license, or your future. Priority one is to purchase nurse liability insurance (and do it now) before swiping in for your next shift. Priority two is remaining vigilant—with every patient, every shift– about what you are documenting, why you are documenting, and how you are documenting it. Doing it defensively could make or break not just a case—but your career: ”Careful and complete documentation of nurses’ progress notes is a principal method of reducing the risk of liability in nursing malpractice lawsuits. They may sustain or preclude a suit for negligence from the outset. They may support or undermine the nurse-defendant before a jury in the event of a trial. In a negligence suit, nursing documentation will be as critical a factor as the nursing care itself. A nurse’s notes should provide answers to questions at issue in a lawsuit. They should not prompt more questions or raise additional issues.” (Sharpe, 1999)
Now you ask, “What makes up defensive nursing documentation?” Simple! Recall the nursing process—it’s the easiest way to remember how to cover yourself. Documentation should include your assessment, identification of patient needs, nursing interventions (in this case teaching methods and materials), and the patient’s response to interventions. Got an opinion about the patient’s overall presentation? PLEASE Leave it out—there’s no room for your subjective impressions of a patient or their situation. Keep it clean and objective. I know the Emergency Room is an exceedingly busy place to try and be effective as a nurse, but it goes without saying that slowing your roll and paying attention to little details like ensuring a patient actually signs the discharge paperwork is a vital part of the process and a big part of reducing liability to you and your institution. The old adage still holds just as true in the courtroom as it does in our practice environments: “If it wasn’t charted it wasn’t done.” Attorneys have a hell of a time trying to defend your course of action if there is no proof the actions really took place: “The defendant’s attorney will endeavor to show that, although there may be an apparent omission, the action in question was the nurse’s usual practice, which routinely need not be documented. Nurses cannot possibly function as court reporters or stenographers, transcribing the minute details of every event or conversation. However, if a nurse defendant’s notes do not corroborate his or her testimony, the nurse defendant will be challenged to persuade the jury to accept as credible his or her version of the events surrounding the alleged negligence. Regardless of he sworn testimony, the written entries in the medical record will serve as the definitive statement of what actually transpired.” (Sharpe, 1999)
When preparing to discharge a patient, ensuring that you have documented your method of teaching, teaching content, as well as the patient’s return demonstration or verbalization of understanding confirms that the patient actually engaged in a conversation with you, had the opportunity to ask questions and voice concerns, and was satisfied with the information they received. Ask the patient if they are satisfied with their teaching session or the materials they received—if the answer is yes, you can add in a simple phrase stating: “patient verbalizes satisfaction.” Incidentally, satisfaction with the discharge process is a large predictor of whether or not patients will be readmitted to the hospital within 30 days with preventable complications. (ie: Coumadin toxicity in patients new to the therapy) A large quantitative study published in the American Journal of Managed Care reports that:“A substantial proportion of Medicare beneficiaries experience an unplanned hospital readmission within 30 days of discharge. Hospital readmission rates are an important measure of the quality and costs of healthcare. Recent estimates suggest that almost one-fifth of Medicare beneficiaries discharged from a hospital are readmitted within 30 days, resulting in an estimated annual cost of unplanned readmissions of $17.4 billion.1,2 Although factors outside of the hospital contribute to unplanned readmissions,3,4 the fact that one-quarter of readmissions occur within 30 days of discharge suggests that there is room for improvement in the quality of inpatient care and discharge planning.” (Boulding, 2011) So there’s a little inspiration for you outcomes driven nurses. Need a little more incentive? Here’s the take home message: Neglecting to effectively document any part of patient care is considered an act of omission that is just as detrimental to your professional well-being as failing to obtain the patient’s signature on any document that involves their care. After all, you know what they say… “The patient is always right.”
Boulding, W. G. (2011, January 25). Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days. Retrieved May 19, 2013, from American Journal of Managed Care: http://www.ajmc.com/publications/issue/2011/2011-1-vol17-n1/ajmc_11jan_boulding_41to48/1
Sharpe, C. (1999). Nursing Malpractice: Liability and Risk Management. Westport, CT, United States: Auburn House. Retrieved May 19, 2013
Tammelleo, D. (2010, February 1). NY: missing signature on discharge summary: does this mean no instructions were given? Retrieved May 20, 2013, from The Free Library: http://www.thefreelibrary.com/NY: missing signature on discharge summary: does this mean no…-a0221907925