Many
trauma professionals believe that they can only be sued if they make a medical
error and some harm occurs. Unfortunately, this is not entirely true. Yes,
this is one obvious way to spark a suit or claim.

Unfortunately, it goes beyond that. Your patient
may sue you if they even believe that
they were harmed in some way, or think that something untoward happened while
you were providing care. Here are the top 10 reasons for getting sued and my
thoughts on each (in no particular order).

#1. “What
we have here is a failure to communicate”

Your interpersonal skills are at least as
important as your clinical skills! You may be a clinical prodigy, but if you
are an asshole at the bedside, your patients will never appreciate your skills. You must be able to listen and
empathize with your patient. Sit down, look at them eye to eye. Listen
attentively. Don’t appear to be in a rush to get out of the room. You’d be
surprised at how much more valuable information you will get and the
relationship you create.

#2. “Work
not documented is work not done” (This is my quote and it’s one of my favorites.)

Accurate, complete, timely, and legible
documentation is a must!
The legibility problem is fading with the widespread use of electronic health
records (EHR, although this is creating new problems). Documentation, or lack
thereof, will not get you sued by itself. However, if you are involved in a suit or claim
and your care is scrutinized, poor or missing documentation will make it
impossible to plausibly contend that you did what you say you did. 

It’s
critical that you document every encounter thoroughly enough to be able to
reconstruct what you were thinking and what you did. And providing a date
and time is absolutely critical. This is especially important when the EHR
timestamps everything you enter. Frequently, you will be documenting something somewhat
after the fact. Always make sure that it’s not too far after the fact. Document as promptly as you can, and
include the time that you were actually providing the service. 

And
never go back and try to “correct” your documentation, especially if the chart
is being requested for inclusion in a suit or claim. If you believe there is an error, create an addendum and explain why the correction
is necessary. If a suit or claim has been started, do not touch or open the
chart without advice from your legal counsel.

Stay tuned for Part 2 tomorrow!