Adequate documentation in the emergency department to mitigate malpractice risks

Authored by:

JoAnn Lazarus, MSN, RN, CEN, FAEN, Managing Partner, Emergency Department Services, Peregrine Health Services, LLC

Scott Kurlander, Esquire, Founder, SPK Consulting & Mediation, LLC

The Emergency Department (ED) is a high stress, high risk clinical environment, where quick decisions and rapid patient turnover is the norm. In this challenging environment the potential risk of medical malpractice claims is always present. Medical malpractice happens when the standard of care is not met, and patient harm occurs. Adequate documentation serves not only as a communication tool among healthcare professionals, but also protects providers against potential legal claims.

“Adequate documentation serves not only as a communication tool among healthcare professionals, but also protects providers against potential legal claims.”

There are many factors in emergency medicine that contribute to malpractice claims. Long lengths of stay in the ED and incorrect prioritization of care can lead to worsening of the patient’s condition. ED providers often work with limited patient information which may lead to mis- or incorrect diagnoses, leading to negative patient outcomes.

Documentation plays a pivotal role in providing effective patient care. The documentation in a patient’s chart is a chronological record of the care the patient received, from initial presentation through to discharge or admission. This record allows any healthcare professional to understand the patient’s journey. Comprehensive documentation ensures continuity of care, reducing the risk of oversights or repeated procedures. The documentation also provides the clinical reasoning, particularly for unconventional decisions or treatments. 

Documentation serves as a strong defense mechanism in malpractice cases. In legal disputes, the patient’s medical record serves as the primary source of evidence, as it is a contemporaneously recorded document before the thought of any claim or litigation ensues. Appropriate documentation can demonstrate that the care provided was in accordance with established protocols and standards of care. Obtaining informed consent for treatment is critical and must be accurately documented. This confirms that the patient was fully informed about the risks, benefits, and alternatives of any procedure or treatment. Attention should be paid to a more specific description of the informed consent discussion as opposed to a general statement that such a conversation took place. When a patient declines or refuses a treatment or procedure, it is also important to document their refusal as well as their understanding of the associated risks of declining. For patients who leave without being seen, documenting instructions, advice given, and any risk warnings is imperative to defend against allegations of neglect or inadequate care.

The fast-paced nature of the ED, coupled with the inherent liabilities of its operations, highlights the importance of thorough documentation. While communication and care continuity are the primary function of documentation, it also plays a critical role in protecting healthcare providers against malpractice claims. Promoting patient safety and protecting providers should remain at the heart of delivering high quality emergency care.