documentation of obstetrical emergencies · obstetrical emergencies craig m. harris and mary ashley...
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Documentation of Obstetrical EmergenciesCraig M. Harris and Mary Ashley Cain, M.D.9-17-2016
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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
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OBGYN Experience
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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
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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%)
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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
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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
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Improving Litigation Outcomes
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THE CHART IS YOUR BEST WITNESS
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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
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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
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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
•
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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
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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.
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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
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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
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Questions?
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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
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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.
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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
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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
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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
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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