Documentationandotherlegalconsiderationsinhealthcaresettings

MidwiferyandMaternal&ChildHealthConference30July2016KarenCusackCorporateCounsel,TheRoyalWomen’sHospital

Introduction

Accountability

Whatis‘accountability’?• moralandlegalrequirements• responsibilityforownactions• answerabletoahigherauthority

Accountability

Sourcesofaccountability:• HealthPractitionerRegulationNationalLaw(Victoria)Act2009

• Commonlaw• EmploymentContract

Accountability

Sourcesofaccountabilitycontd:• PolicyandProcedureManuals,Guidelines,Practice• ScopeofPractice

– Lawfulness– Policy– Practice– Competency– Education– Knowledge– Qualifications– Accountability– Responsibility

Accountability

Howdoesaccountabilityplayoutinthelegalarena?• Coroner’sCourt• Civilactionfordamages• Criminalprosecution• NursingandMidwiferyBoard• VCAT

Accountability

YOUAREACCOUNTABLE• Goodpractice• Gooddocumentation• Followdirections,policies,proceduresandlegalduties

Documentation

• Authenticity• accurate• dateandtime• nameand signature• designation

• Timeliness• Contemporaneous

• Legibility• Goodforlegalreasonsandappropriatepatientcare

Documentation

Mainissues:• Litigationmaytakeyears• Memoriesarefallible– Patients/familiesmemoriesarenotasfallible

• Themedicalrecordwillusuallybetheonlyrecordofanevent.

Documentation

• e.g.Schedule8Drugs• s32 requiresrecordingof:

• detailsoftheSchedule8drug;• quantities;and• anyotherprescribedparticulars

• MustberecordedbyPRINTINGorWRITINGINALEGIBLEFORM–s32(2)

• Penalty– 60penaltyunits(approximately$9,500)

Documentation

NONOTESorINTENTIONALLYINCORRECTNOTES– NODEFENCE!

• beingtoobusytodocumentortofollowapolicyoraprocedureisneveradefence;

• noriswritingsomethingthatisknowntobeincorrect.

CaseStudy1

CaseStudy1- Facts:• patienta48yr oldmanwhowasadmittedtoaclinicwhichwaspartofthepracticeofaregisteredpsychologistfor‘rapidopiatedetoxification’

• theRODoccurredover24hoursduringwhichtimearegisterednursewascaringforthepatient

• followingRODthepatientwasreturnedtohishome

• Thepatientbecameunwellandwasadmittedtotheemergencydepartmentandsubsequentlydied

CaseStudy1

ComplaintallegedthattheNurse:• Failedtocarryoutobservationsofwithdrawalscale,temperature,

pulse,bloodpressureandrespiratoryrateatappropriateintervalsonPatientAincontraventionoftheClinicpolicy

• OR,iftheNursedidcarryoutobservationsthenhefailedtorecordobservationsofwithdrawalscale,temperature,pulse,bloodpressureandrespiratoryrateatappropriateintervalsonPatientAincontraventionoftheClinicpolicy

• Failedtoappropriatelymaintainthefluidbalancerecordoverthecourseofthepatient’sadmissionattheClinic.

• Failedtomaintainanadequatestandardofdocumentationontheobservationchartorinthenursingnotesinthepatientrecord.

• Failedtorecordtimeanddateofmedicationadministrationonthemedicationchart

CaseStudy1

Nursing&MidwiferyProfessionalStandardsHearing:• Admissionsmadethatheconsideredthathehadmadeseriouserrorswhilecaringforthepatient;

• Deepregretrepatient’sdeathandthecomplaintprocess.

CaseStudy1

Ordersmade:• Registrationlapsed,but• Ifreappliesmustcomplywithvariousordersandconditionsimposedincluding:• Supervision,educationandrestrictionsontheareaofpractice(i.e.notpracticenursingintheareasofDrugandAlcoholormentalhealth,oranyotherareawhichisnotconsideredtobeinhisscopeofpractice,educationorexperiencebythesupervisor)

CaseStudy2

CaseStudy2- Facts:• Patienta70yr oldmanwhounderwentalaparoscopic

cholecystectomy• transferredtothe‘ExtendedDayOnly’unitandhadbeen

experiencingpain.• assessedbyadoctorandanordermadeforincreasedanalgesia

(15mgmorphine).• thenextmorningthepatient’stemperaturewas38degrees,

heartrate120bpm andsystolicBPhaddroppedto80mmhg.Amedicalemergencyteamcallwasmadeandthepatienttakenbacktotheatrewhereaperforatedbowelidentified.

• duringthenightshifttheRespondentwastheonlymemberofstaffrosteredtoworkintheEDOunitandwasresponsibleforthecareofPatient.

CaseStudy2

Particularsofthecomplaintthat,duringthenightshift,theRespondent:1. Failedto:

a.performand/orb.documentacompletenursingassessmentofthe

Patient;2. FailedtoarrangeforthePatienttobereviewedbyamedicalofficerat2400hrs whenthepatienthadatemperatureof39degreesandapulserateof126bpm.

CaseStudy2

3. FailedtomonitorthePatient’stemperature,pulseandbloodpressurebetween2400hrs and0600hrs,or4. IftheRespondentdidmonitorthePatient’stemperature,pulse,bloodpressurebetween2400hrsand0600hrs she:a. failedtodocumentherobservationsinthePatient’smedicalrecord.b. failedtorecogniseand/oractuponanydeteriorationinthePatient’scondition.

CaseStudy2

5.InregardstotheadministeringofMorphine15mgs/cat0040hrs theRespondentfailedto:

a.i. conductand/orii. documentanursingassessmentpriorto

administeringthemorphine,toascertainthereasonforthePatient’spain.

b. documentinthePatient’smedicalrecordtheadministeringofthemorphine.

CaseStudy2

TribunalFindings:• Itisthefailuretorecordsomanyobservationsthatplacesthisconductsignificantlybelowtheexpectedstandard.

CaseStudy2

Orders:• formalreprimand• conditionsplacedonregistrationincluding:

• Toundergospecificnursingcourses• TonotifyhercurrentandanysubsequentemployeroftheTribunal’sfindings

Summary

DOCUMENT,DOCUMENT,DOCUMENT!

Anyquestions?

Karen CusackCorporate Counsel

karen.cusack@thewomens.org.au