When an adverse event occurs in a health care setting, the moments and hours that follow are critical, not only for the patient’s continued care, but also for the physicians, practices, and hospitals involved.
How the event is documented, how disclosure is handled and how the subsequent investigation is recorded can shape everything from clinical outcomes to legal exposure years down the road.
Physicians are increasingly open to disclosing adverse events to patients and families, but the documentation supporting those conversations is often inconsistent which can undermine even the best-intentioned disclosure practices, leaving providers vulnerable when memories fade and details blur.
“Documentation is essential for many reasons including patient care, and continuity of care when multiple specialties are involved. But it’s also valuable should the matter be subject to litigation,” said Tara Eichman, Senior Risk Management Consultant at ProAssurance, Part of The Doctors Company.
“Years after an event, physicians may no longer recall the details of a situation, and that makes contemporaneous documentation the most reliable record of what occurred.”
You can read the full article here.