“MD aware.” What a lawyer asks about a notification note
Exhibit 5 any shift
MD aware.
Aware of what, and since when? It does not say who you reached, what you told them, or what they said back.
What they ask about it
A nursing-home defense firm, on what plaintiff's counsel asks the doctor
Plaintiff’s counsel will often schedule the deposition of a treating physician and inquire as to whether the nursing home staff timely made the physician aware of an issue or if the physician would have liked to have been made aware of an issue. Plaintiff’s counsel is hoping that, in an effort to avoid being sued, the treating physician will turn on the facility and testify that he/she was not timely notified or would have liked to have been notified of an issue by the nursing home staff.
The same firm, on a chart with no baseline before the change
The most common scenario where this issue plays out is when there is little or no documentation in a resident’s chart and then suddenly there is documentation of a change in condition. Without prior documentation confirming that the resident was status quo just prior to the change in condition, it is difficult to establish that the resident’s treating physician was timely notified of a change in condition.
The nurse's note said only “refusing to be admitted. M.D. aware.” At trial the gap was filled by the doctor's own dictated notes and his testimony about his routine practice, which the court allowed as habit evidence.
Dr. Hardwick sees thousands of patients each year and could not recall Mr. Thomas specifically. Based on his dictated chart notes and customary practice in treating chest pain patients, Dr. Hardwick testified that he urged Mr. Thomas to be admitted for observation and testing but he refused. An attending nurse gave similar testimony about her handwritten chart notes, which said the patient was "refusing to be admitted. M.D. aware."
Texas Court of Appeals, 5th District (Dallas) · 1997
A fall note ended “MD notified.” and did not say why the patient fell, so the nurse could only testify to her normal practice. The judgment for the defense was affirmed on other grounds.
Cha-son testified that her normal practice when a patient fell would be to ask the patient what had happened and write down the reason. Chason testified that if Malone had told her why he fell, she would have noted the reason on both the chart and the patient occurrence report.
Write instead
14:01: Urgent page placed through hospital operator to Dr. Patel, covering physician. Message included new confusion, BP 86/50, HR 124, RR 30, and SpO2 88% on room air; requested immediate bedside evaluation and callback to unit number. 14:03: No callback received.
Record any phone call to a physician, including the exact time, message, and response
Don’t chart “I left a message.” Nurses have a duty to advocate for the patient. If you do not hear from the doctor, you have to call back, or call another doctor or ask your supervisor what to do.
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Not legal advice. Your facility policy, your state and your
own attorney are what bind you. Every question and every quote here links to
where it was published; read the source, not us. Written by a med-surg RN,
ten years, day shift. Why there is no name on it.