One of the most important actions for medical providers in the situation described last week is meticulous and frequent documentation of every interaction with the patient. All treatment, instructions, evaluations, physical observations, and advice not to leave must be clearly documented in the records. In the New York case, scrupulous documentation was extremely helpful to the defense. Clear, accurate documentation is a must in all heath care settings, and is of particular importance in a situation that could pose a potential danger to the impaired person or those with whom he/she may come into contact.
“If it’s not written down, it didn’t happen”
This month’s civil topic is “Patient Safety: Intoxication” Areas of discussion:
- Case Scenario (9/1/14)
- Documentation (9/8/14)
- Policies (9/15/14)
- TBD (9/22/14)
Note: To see all posts in this topic, click here.