Every physicians office sees repeat patients. But no matter how often a procedure is performed, health care professionals must fight the urge to let their guard down and provide less than standard patient care.
A 55-year-old male sustained a disabling work-related back injury approximately 10 years previously. After sustaining this injury, he began making a two-hour trip from his home several times a year to receive cervical spine injections for neck pain and migraines. The physician clinic where the injections were administered had very inconsistent record-keeping relative to post-injection monitoring of the patient before he was cleared to be discharged.
The patient underwent approximately 25 to 30 of these injections over a 7-to-8-year period with no complications. Sometimes the records clearly documented the time the injection was given, the monitoring of the patient for 20-30 minutes post-injection, and the time of the patient’s discharge from the clinic. However, on some occasions, there were holes in the post-injection documentation.
On the day that became the subject of a medical malpractice claim, the patient alleges that he told the staff that “something wasn’t quite right” and he was having “pain between the shoulder blades.” The staff testified that if they had indeed received such complaints, they would not have allowed the patient to leave the facility. The charting on that particular day did not indicate any patient post-injection complaints. Unfortunately, the chart had scant post-injection documentation and nothing at all as to the time the patient was discharged.
After leaving the facility, the patient drove for about 15 minutes when he began experiencing numbness in his chest and extremities. He pulled off the side of the road and flagged down a police car. An ambulance was summoned and transported the patient to a nearby hospital. He was diagnosed with a C7-T3 epidural hematoma and underwent a T1-T3 laminectomy with evacuation of the hematoma. He underwent considerable post-incident medical care and experienced some permanent functional residuals.
The Medical Review Panel found no malpractice relative to the actual administration of the injection, but found a breach in the standard of care for failure to adequately observe the patient following the injection. The panel found an issue of fact as to whether the patient voiced post-injection complaints to staff, but found the charting to be significantly lacking as to post-injection monitoring of the patient.
The medical chart is always the most important piece of evidence in a medical malpractice complaint. It has to tell the complete story from an objective point of view. Gaps in charting almost always benefit the plaintiff. The timeliness of treatment and/or communication is usually a part of the story so the documentation of times along with the correct time (a.m. or p.m.) is crucial.
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