PART I- The Investigation ........................................ 1
Chapter 1-Reviewing the Medical Record........................... 3
Kathleen Ashton, BSN RN
When to Review Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Reviewing Notices for Potential Claims .................. . . . . . . . . . 11
Reviewing a Medical Record for Investigation .. . .................... 15
Tips for Managing Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 2-Locating Other HCO Documents ....................... 21
Kathleen Ashton, BSN, RN
Clinical Documents ............... . . . ................. ....... .22
M iscellaneous Documents .. . . . ....... . . . . . . . . . . . . . . .. . . . . . . . . . . . . 27
N otes . . . . . . . . . . . .. . . . . . . . . . . . . . ..... . . . . . . . . . . . . . . . ... .... ........... 30
Chapter 3-The Electronic Health Record: Getting It All Together...... 31
Robert Stanyon, MS, RN, CPHRM, FASHRM
Assembling the Electronic Health Record . .. ..... ..... . .............. . . . . . . 31
Working Paperless . ......... ......................................34
Where to Begin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
N otes ..................... .......... ... ............ ....... . . . . 38
Chapter 4-Identifying the Medical/Legal Issues.......... ........... 43
Kathleen Ashton, BSN, RN
W hat Is a M edical/Legal Issue? . . . . . . . . . . . . . . . . . . . . . . . . . . ............... . . . 43
A nalyzing the Facts . . . . . . . . . . ................................................... 45
Identifying Individuals to Be Interviewed ................. . . . . . . ...... 51
Chapter 5-Interviewing Techniques........... . . . .... .......... 51
Kathleen Ashton, BSN, RN
Setting Up the Interview ................ . . .......... . . .... .... 53
Beginning the Interview............... .................... . . . . . . 58
Some General Guidelines for the Interview. ...........................58
Closing the Interview . . . .................. . . . . . . . . . . . . . . . . . . . . ..... 62
The Difficult Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . ... . 63
Listing the Goals for Each Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Chapter 6-Preparing for Interviews. .............................. 65
Kathleen Ashton, BSN, RN
Doing Som e Research . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . . 66
Preparing a List Of Questions ................. ................. . . . . . 67
Chapter 7-Developing Interview Questions on
Specific Occurrence Types ................... ....... . .. 71
NancyAcerbo-Kozuchowski, RN, MS, CPHRM and Kathleen Ashton, BSN RN
with David Feldman, MD, MBA, Joseph Schappert, MD, VilmaA. Joseph, MD, MPH,
Gregory M Asnis, MD
Slips and Falls ..... .............. . . . . . . . . . . . . ..... ........... . . . . . . . 72
Intravenous Infiltrations . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . 74
M edication Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . ... . 75
Failures to D iagnose . ..................... ........................ 76
The Usual Symptomatology of the Disease/Condition
Missed on Diagnosis Should Be Reviewed ............... ... .... 76
Surgical Mishaps/Technical Accidents at Surgery/Poor Surgical Outcomes . .. 77
Postoperative Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Anesthesia Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 80
Suicide-Related Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Clinical Laboratory Errors ................... ...................... 87
Blood Bank Occurrences ............... ................... . . . . . . . 89
Pathology Lab Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... 90
Radiation Therapy Occurrences ............................... . . . . . 90
Inform ed Consent Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Gastroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
N o te s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3
Chapter 8-Developing Interview Questions on
Occurrence in Long-Term Facilities ..................... 95
Jose Guzman, RN MS
Documenting and Asssessing the Plan of Care .. . . . ........ . .......... 96
Q uestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
N otes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 7
Chapter 9-Developing Interview Questions on Obstetrical Claims .... 109
NancyAcerbo-Kozuchowski, RN, MS, CPHRM and Irene Kassel, BSN, RN
with Peter Bernstein, MD, MPH
Antepartum--Prenatal Period . . . . . . . . . . . . . . . . . . .. . ... ......... . . . . . . 110
Intrapartum-Labor and Delivery ................... ....... . . . . .... 113
Postpartum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Other Major Obstetrical Complications Associated with Pregnancy, Labor,
Delivery, and the Postpartum Period . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Chapter 10-Investigating Equipment-Related Occurrences .......... 129
Patricia Kischak, RN, CPHRM with Allison M. Barth, Esq.
Safe M edical Devices Act . . . ................................. . 130
Products L iability . ..............................................131
The Investigation ............... ...................................... 133
Chapter 11-Reviewing and Maintaining the Claim File ............. 143
Ruth H. Axehod, RN, JD
W hat Is in the Claim File? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 143
Glossary of Terms . ........... . . . . . . . ..... . . ......... ..... . . 145
Notes .. ...... . .............. . . .. . . . . .. ..... . .... . 153
Chapter 12-Writing the Investigation Report............. ............ 155
Kathleen Ashton, BSN, RN
Objectives of an Investigation Report ......................... . 156
Guidelines for Using the Investigation Report Format................... 156
Sample Investigation Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Guidelines for Writing an Obstetrical Investigation Report. .. ...... ..... . .. 219
Sample Obstetrical Investigation Report . . . . . . . . . . . . . . . . . . . . . . . . . 231
N otes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. . . . . . . . . . .23 1
Appendix 12-A-FOJP Service Corporation
Investigation Report (Blank) .................. .... 232
Appendix 12-B--FOJP Service Corporation Obstetrical
Investigation Report (Blank) ...................... 237
Appendix 12-C-Blank Form for Test Results ...................... 246
Chapter 13-Additional Investigation ............................. 249
Kathleen Ashton, BSN, RN
Investigation During the Discovery Phase . . . . . . . . . . . . . . . . ......... 249
Responding to Defense Attorneys' Requests for Information ......... . .. 250
Preparing Follow-Up Investigation Reports. . . . . . . .. ... . . . . . . . . .. . 251
Sample Follow-Up Investigation Report Form......................... 251
Appendix 13-A-FOJP Service Corporation Investigation Report...... 252
PART II-Additional Topics Related to Medical Malpractice
Claim Investigation ................ .............. . . . . . . . 257
Chapter 14-Confidentiality of Medical Records and Other Documents .. 259
Karen H. Geller RN, JD
Health Insurance Portability and Accountability Act (HIPAA),
State Regulations, and Personal Health Information (PHI)....... ...... 259
Releasing PHI without Patient Authorization . . . . .... . . . . . . . . . . . . ... 260
Patient Access to PHI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Releasing Records of Psychiatric, Substance Abuse,
and/or HIV-Related Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 262
Sharing Confidential Information With Government Agencies. .... . . . . ... 263
Protecting Confidentiality During Litigation..................... . . . . . . 264
Additional Practices That Safeguard Confidentiality................ .... 269
Chapter 15-What the Investigator Needs to Know about Insurance ... 273
Steve Macaluso, Esq.
Insurance Mechanisms .... . . . . . . . . . . . . . . . ....... . . .......... . . 273
Glossary of Insurance Terms ................... ........ . . . . . . . . . ??274
Chapter 16-The Life of a Medical Malpractice Claim............. .. 283
Ruth H. Axe-rod, RN, JD
M alpractice D efined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Commencement of a Medical Malpractice Lawsuit ... . ...... . . . . .. .. 286
Pleadings. . . ........... . . . . . . . ................... ............ 287
Pretrial Discovery............................................... 288
M otion Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
T he T rial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 290
Verdicts/Damages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Post-Trial M otions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
A ppeals. . . . . ............................................ .. 293
Chapter 17-Informed Consent .................................. 295
Steve Macaluso, Esq. with Allison M. Barth, Esq.
G eneral Principles ..............................................296
Documentation of Informed Consent......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Consent by Other Parties for an Adult Patient ......... . . . . . . . . . . . . . . 301
Consent for Treatment of Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Special Situations Involving Consent. ....... . . . . . . 303
Advance Directives . . . . . . . . . . . .............. ...................... 305
Practical Implications for Claims Investigation . .... ... . . . . . . . . ... . . . 307
Notes . ....... ......... . . . . . . ... . . . . . . . . . . . .... . .... . 308
Chapter 18-Responding to Adverse Occurrences and
Potential Lawsuits. . . . . . . . . . . . . . . .. . . . . . . . . .... . . . . . . . 309
Monica Santoro, RN, CPHRM, CPHQ and NancyAcerbo-Kozuchowski RN, MS, CPHRM
Responding to Patient Complaint Letters. ............................ 309
Screening Incident/Occurrence Reports, .......... . . . . . . . . . . . . . . . 310
Responding to Serious Adverse Occurrences. . . . . . . . . . . . . . . . . . . . . . . . . . 312
Preventing Reccurrences .........................................313
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 317
Chapter 19-Claim Management ............................... . 319
Ruth H. Axe/rod, RN, JD
Planning a Defense Strategy .......... . . . . . ................... 320
H andling a Sum m ons.. ...........................................321
Setting Loss and Expense Reserves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Choosing a Medical Expert ........................ . ....... 327
Costs of Defending a Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Reviewing Defense-Related Bills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Claim Conferences . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . ... 329
Negotiating a Settlement . . . . . . . . . . . . . . . . . . ..... . . . . . . . . . . . . . 329
Attending the Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Settling Claims Made Prior to Litigation . . . .. .. . . .. . . . . . . . . . . . 330
Setting Priorities for Investigations . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 331
Chapter 20-Writing the Report Clearly and Concisely .............. 335
Lori Breslow, PhD
A udience A nalysis . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 335
Concise W riting . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 336
Coherent W riting . . . . . . . . . . . . .. . . . . .. . ... .......... . . . ... . . . . . . . . . 338
Error-Free W riting ..............................................340
R esources . . . ........... ............................... . 340