David S. Barmak Health Care Law Blog on Lawyers.com

Documentation is the Key to Winning or Losing a Lawsuit

Wednesday, October 19, 2011 by David S. Barmak



DOCUMENTATION IS THE
KEY TO WINNING OR LOSING A LAWSUIT



 



David S. Barmak, Esq.



 



Our firm defended a case in
which an extremely ill, middle aged woman came to my client’s nursing
home.  She had severe circulatory problems.  She went back and forth
many times to a nearby hospital. Every time she returned from the hospital, she
had a stage 3 decubitus ulcer. The hospital recorded in the chart that it
discharged her with a stage 2 decubitus ulcer. We are all seeing this
discrepancy because of reimbursement considerations. Unfortunately, these
intentional misidentifications result in ultimate liability for our nursing
homes. Our client performs one miracle after
another in healing all of the decubitus ulcers. Sadly, the resident did not
return from her last hospital visit because she died.  The family sued our client, the nursing home and did not sue the
hospital. The family acknowledged that she developed ulcers in the hospital;
however, they claimed that these ulcers never healed in the nursing home. 
They were wrong but the nursing home chart did not definitively show that the
ulcers had healed. The nursing home chart was not complete because of sloppy
documentation.  After three and a half years of litigation, the insurance
carrier decided, against my recommendation, that the case was not
defensible.  The insurance carrier settled for many thousands of dollars.



 



 The point of this story is that your staff can provide
miraculous care but like the tree falling in the woods, miraculous care without
complete and accurate documentation goes unheard during a lawsuit.



 



 



Posted at 15:59 PM
Topic: Health Care
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