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The author is a health care attorney who specializes in risk management issues.
Never feud with nurses on the patient's chart; forwarding the records of other physicians.
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Q:A nurse at my hospital wrote up an incident report about me and sent it to the director of nursing. Her remarks were totally inappropriate. Should I write a note in the patient's chart explaining my side of things?
A: No. Respond orally or in writing to the director of nursing if you wish, but never use a patient's chart as a forum for dispute with another health professional. You could be inviting a malpractice suit.
There are occasions when a nurse is so annoyed by a doctor's actions that she'll "write up" the incident. I've seen such reports about failure to respond to calls from nursing, or about a physician's leaving a sponge in a patient after surgery. Other times, a physician may be involved in a nursing incident, such as failing to order the side rails of the bed to be raised, or writing the wrong dosage.
In the case of a patient injury, the physician may be asked to enter his findings directly on the incident report. But even then, never engage in defensive counterattacks. Stick to the facts: What happened? What are the outcome and recommendation?
If the patient ever decides to sue, anything in his records can be discovered by his attorney. It's unlikely that the lawyer would even be aware of an incident report unless the physician mentioned it specifically in the patient's chart. The attorney would then demand a copy of it. While the hospital may resist, incident reports have been released to attorneys in several jurisdictions.
Don't give in to the temptation to blame the nurse in writing. Physicians have complained that a sponge was left in a patient's body because the nurse gave the wrong count. Or that the reason the doctor didn't restrict a patient's out-of-bed privileges was that the nurse never reported to him that the patient was unsteady on his feet. Jousting like this in the patient's records brings a smile to the face of the plaintiff's lawyer. He won't need to work hard to make his case, since the doctor and nurse are finger-pointing and doing his work for him.
Write a note in the chart if you need to examine the patient and decide on a course of treatment to correct any problem or incident. But don't mention any incident reports and don't cast blame on anyone.
Q:A patient is relocating to another state, and she's asked me to forward her records to her new doctor. In her chart, I also have copies of her treatment records from her previous physicians. Should I forward these records, as well?
A: No. Once you receive a written authorization from the patient, you may transfer copies of only the records you generated. Keep copies of your records, and of those forwarded to you by other doctors; they could assist in the defense of any claim that might be filed later. After all, your treatment decisions were likely influenced in some way by the patient's prior history.
However, releasing records originated by other physicians isn't permissible. It could constitute a breach of confidentiality unless the patient specifically authorized you to do so. Even then, it's best to tell the patient to ask her previous physicians to release those records, and to send them authorization forms.
Lee Johnson. Malpractice Consult. Medical Economics Jul. 24, 2000;77:121.