Documentation of Obstetrical EmergenciesCraig M. Harris and Mary Ashley Cain, M.D.9-17-2016

Objectives

Discuss OBGYN experience and litigation

Review Florida respondents experience with litigation

Identify how to improve litigation outcomes

Discuss the significance of EMR and documentation

OBGYN Experience

Litigation and Obgyn

2012 ACOG survey on professional liability

9,006 completed surveys

77.3% of OBGYN report being involved in at least one liability claim

Average 2.64 claims per Obgyn

42% reported claims arose during residency

51% changed practice due to cost of liability insurance

58% changed practice due to fear of litigation

Litigation and ObGyn

Top Ob allegationsNeurologically-impaired infant (28.8%)

Stillbirth/neonatal death (14.4%)

Delay/failure to diagnose (11.1%)

Top Gyn allegationsPatient injury -major (29.1%)

Delay in or failure to diagnose (22.1%)

Patient injury -minor (20.7%) (20.7%)

Florida Respondents

90.9% of respondents reported at least one liability claim

74.6% made changes to practice as a result of fear of claims

69.7% made changes as a result of availability/affordability of malpractice insurance

Florida respondents Fear of litigation

Stopped offering/performing VBAC 39.4%

Decreased number of high risk obstetric patients

37.1%

Increased number of cesarean deliveries 31.2%

Decreased number of total deliveries 14.9%

Stopped practicing obstetrics 9.5%

http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyDistrictFlorida.pdf

Obstetrical practice changes

Improving Litigation Outcomes

THE CHART IS YOUR BEST WITNESS

Strong DocumentationImproves patient care

May prevent a lawsuit from being filed

Easier to find expert support

Juries appreciate detail oriented physicians

Improves your testimony

Makes your deposition less stressful

Makes your lawyer’s job easier

Critical Points

Times

Risks and Benefits

All Conversations with Patients

All Conversations with Consultants

Details of maneuvers

Leaving Against Medical Advice

Do not to be critical of patient/staff/other physicians

Leaving against Medical Advice

• Patient leaving AMA

• Likely Litigious

• Use the standard form

• Ensure signature prior to leaving

• Hospital copy included in patients medical

Document conversation

specific risks of refusing care

Patient reasoning for leaving

Avoid dramatic discussions

•

EMRs

Do not become overly reliant on templates

Sometimes you will need to create your own note to include all relevant information

Be cautious in selecting from drop-down menus

Revisions and Addendums

Do not make substantive revisions to note

Especially weeks or months later

And/or when there is a bad outcome

Self Serving

Makes a good case for a plaintiff virtually unwinnable for the defense and gives some traction to a bad case for the plaintiffs.

Handling Bad Outcomes

Talk with the patient and family

Engage in active listening

Review the sequence of events

Provide facts

Document the conversation

Be available, do not disappear

Moving forward

Develop incident specific templatesACOG documentation guide for shoulder dystocia

http://www.acog.org/-/media/Patient-Safety-Checklists/psc006.pdf?dmc=1&ts=20150324T2004442213

Questions?

EMR and Documentation

• Review of closed claims in the Albert Einstein College of Medicine System o seven cases in which care was compromised due to a missing or

incomplete prenatal chart.

o Shoulder dystocia when delivering MD was unaware of ultrasound noting macrosomia

George and Bernstein, Current Opinion in Obstetrics and Gynecology 2009, 21:527–531

EMR and Documentation• 2005 qualitative and quantitative study of housestaff interaction

with computerized order entry

• Concluded electronic systems lead to 22 types of medication errors

o Fragmented displays

o Mistaken dosage guidelines

o Double dosing facilitated by separation of functions

o Inflexible ordering formats

o ¾ of participants witnessed these errors one or more times per week

Koppell et al. JAMA 2005. 293; 1196-1203.

EMR and Documentation

• 2005 Cross-sectional survey

o 263 physicians and 1614 clinical visits

o Clinical information reported missing 13.6% of visits

o 44% of missing information somewhat likely to adversely affect patient care

o Missing information less likely in settings with an EMR (OR, 0.40; 95% CI 0.17-0.94).

Smith et al. JAMA 2005 , 293: 565-571

EMR and Documentation

• 2005 Cross-sectional survey

o 263 physicians and 1614 clinical visits

o Clinical information reported missing 13.6% of visits

o 44% of missing information somewhat likely to adversely affect patient care

o Missing information less likely in settings with an EMR (OR, 0.40; 95% CI 0.17-0.94).

Smith et al. JAMA 2005 , 293: 565-571

EMR and Documentation

• 2005 Retrospective Serial Cross Sectional study

• Following implementation of EMR

o Office visits fell 9%. (P <0.0001)

o No change in use of laboratory and radiology services

o Increase in telephone consults

• Increased comfort with telephone due to availability of information.

Garrido et al. BMJ 2005 330: 581

References

Garrido et al. BMJ 2005 330: 581

George and Bernstein, Current Opinion in Obstetrics and Gynecology 2009, 21:527–531

http://www.acog.org/-/media/Departments/Professional-Liability/2012PLSurveyDistrictFlorida.pdf

Koppell et al. JAMA 2005. 293; 1196-1203

Smith et al. JAMA 2005 , 293: 565-571