Just One Suggested New Year's Resolution - And It's Doable!
A Guest Blog by Donna Vanderpool, MBA, JD, Vice-President of Risk Management
It’s the start of a new year, so I just cannot resist offering one resolution to consider for 2012. Here it is: try to document your patients’ treatment records so that someone else can read the record and understand what happened in your treatment and why. The “someone else” could be another clinician; after all, remember that the primary purpose of a treatment record is for continuity of care. Or, the “someone else” could be related to litigation – a plaintiffs’ attorney, an expert witness, or a jury. Plaintiffs’ attorneys tend not to take cases where there is good care adequately documented (there’s no such thing as a perfect record). They would rather take cases where the documentation is such that it is not clear what the psychiatrist did or why it was done, so the plaintiffs’ expert is able to make up a story about what the defendant psychiatrist did and why. We know that good documentation contributes greatly not only to improving patient safety, but also minimizing professional liability exposure. In medical malpractice cases, courts will defer to the treating physician, as long as there is some basis for that deference. That basis is the treatment record created at the time the treatment occurred.
Have a wonderful 2012!
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|Donna Vanderpool, MBA, JD – Vice President
As Vice President of Risk Management, Ms. Vanderpool is responsible for the development and implementation of PRMS’s risk management services for both The Psychiatrists’ Program and The Neurologists’ Program. Ms. Vanderpool has developed expertise in the areas of HIPAA and forensic practice, and has consulted, written and spoken nationally on these and other healthcare law and risk management topics. She most recently wrote a chapter concerning the risks of harm to forensic experts for Robert L. Sadoff, MD’s book Ethical Issues in Forensic Psychiatry: Minimizing Harm, (Feb. 2011/Wiley). Ms. Vanderpool received her undergraduate degree from James Madison University, and her MBA and JD from George Mason University. Prior to joining PRMS in 2000, Ms. Vanderpool practiced criminal defense law, taught business and legal courses as an adjunct faculty member at a community college and spent eight years managing a general surgical practice in Virginia.