Documentation with a Jury in Mind-View Presentation

Video Transcription

Video Summary

In this video, Kara Staus, an Assistant Vice President in the Risk Management Group for AWACS Services Company, provides a presentation on the importance of documentation in healthcare, specifically in the context of risk management and legal defense. She starts by explaining the elements needed for claims against physicians, such as negligence and breach of standard of care. She then discusses common claims against psychiatrists, including improper assessment, failure to diagnose, improper treatment, vicarious liability, prescribing, failure to provide informed consent, and abandonment. Staus emphasizes the importance of thorough and accurate documentation in defending against these claims.<br /><br />She highlights best practices for documentation, including including all related conversations, documenting special situations like consultations and refusals, and documenting informed consent and refusal. Staus also discusses considerations for handwritten and electronic records, including legibility, timeliness, and use of templates. She emphasizes the need to avoid alterations to the medical record and the importance of clear, concise, and defensible documentation.<br /><br />Lastly, Staus notes that the medical record is a legal document and may be subject to e-discovery, and she advises healthcare professionals to chart with the patient and jury in mind, and to ensure that their documentation accurately reflects the care provided and can withstand scrutiny.

Keywords

documentation

healthcare

risk management

claims

psychiatrists

informed consent

medical record

legibility

e-discovery