patient did not report any previous treatments for this condition

How should the documentation of a patient's informed refusal be?

The documentation of a patient's informed refusal should include the following: identify the potential benefits and risks of the intervention; note that the patient has been told of the risks — including possible jeopardy to life or health — in not accepting the intervention;

What if the patient cannot be reached?

If the patient cannot be reached by the available contact information, try other means including online sources as warranted by the clinical importance of contacting the patient. Assess how reliably individual patients are likely to be contacted and customize your approach.

When is treatment over a patient’s objection appropriate?

KP: A simple example of when treatment over a patient’s objection would be appropriate is if a psychotic patient who had a life-threatening, easily treatable infection was refusing antibiotics for irrational reasons. Treatment would save the patient’s life without posing significant risk to the patient.

Do competent patients have a right to refuse medical treatment?

Competent patients have a right to refuse treatment. This concept is supported not only by the ethical principle of autonomy but also by U.S. statutes, regulations and case law.

What is it called when a patient does not follow treatment?

Non-adherence: is generally a term which includes unintentional refusalby the patient (i.e. patient is overwhelmed, does not understand, helpless, confused, and/or concerned with healthcare costs).

What are the consequences of failure to report in healthcare?

Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported. Practitioners often fear they will gain a reputation for committing mistakes and may not self-report.

Why do patients not report medical errors?

Physicians' training and attitudes place additional barriers to reporting errors. As the gatekeeper for a patient's care, the physician who commits an error, especially one that harms the patient, may feel deep shame, guilt, and a sense of failure.

Why is it important to report medication errors?

Medication errors have significant implications on patient safety. Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.

Why is reporting important in nursing?

Most importantly, communication supports the foundation of patient care. So, hand-off reporting during shift change is a critical process that is crucial in protecting a patient's safety. Throughout the hand-off report, it is vital to provide accurate, up-to-date, and pertinent information to the oncoming nurse.

What is the importance of incident reporting in healthcare?

The reporting of incidents to a national central system helps protect patients from avoidable harm by increasing opportunities to learn from mistakes and where things go wrong.

Why do nurses not report medication errors?

Fear of punishment and legal consequences in clinical practice has always been one of the barriers to error reporting. It is estimated that about 95% of medication errors are not reported due to the fear of punishment.

How many medical errors are not reported?

Most hospitals currently rely on voluntary reporting. A 2011 Health Affairs study, however, found that voluntary reporting missed 90% of adverse events.

When should a medical error be disclosed?

Recommendations suggest that the disclosure be made soon after the mistake occurs. 36 Typically, patients do not expect a medical mistake to occur. Hence, the disclosure timing is important to consider, as are general precautions and best practices surrounding disclosure of all bad news.

What is the importance of correct recording and reporting in medication administration?

They prevent duplication of work, decrease errors and show efficiency level of the staff. Records and reports hold an important place in the process of educational administration.

Who are medication errors reported to?

The U.S. Food and Drug Administration (FDA) receives more than 100,000 U.S. reports each year associated with a suspected medication error. FDA reviews the reports and classifies them to determine the cause and type of error.

What is the most important reason for medication errors to be defined and recognized?

The most common causes of medication errors are: Poor communication between your doctors. Poor communication between you and your doctors. Drug names that sound alike and medications that look alike.

Why is medical treatment unauthorized?

Medical treatment could be unauthorized because the doctor didn’t fully explain either the procedure or the risks associated with the procedure. First, the patient must show that the doctor performed the treatment or procedure without her informed consent.

What happens if a doctor doesn't give consent?

If a doctor fails to obtain informed consent for non-emergency treatment, he or she may be charged with a civil offense like gross negligence and/or a criminal offense such as battery or gross negligence which is the unauthorized touching of the plaintiff's person. In a civil suit, the patient would have to show two elements. Medical treatment could be unauthorized because the doctor didn’t fully explain either the procedure or the risks associated with the procedure. First, the patient must show that the doctor performed the treatment or procedure without her informed consent. Second, the patient has to show that had she known about the risks of the procedure, she would’ve decided not to have it done and, therefore, avoided the injury.

What is the first step in a patient's medical history?

First, the patient must show that the doctor performed the treatment or procedure without her informed consent. Second, the patient has to show that had she known about the risks of the procedure, she would’ve decided not to have it done and, therefore, avoided the injury.

What is informed consent?

Informed Consent. Virtually all states have recognized, either by legislation or by common law, the right to receive information about one's medical condition, treatment choices, risks associated with the treatments, and prognosis.

Is informed consent legal?

The informed consent process isn’t only an ethical obligation for doctors -- it is also a legal one. State laws often take a patient-centered approach.

Can a minor give consent to medical treatment?

Minors, unlike adults, are generally presumed to be incompetent. Therefore, they are unable to give consent to medical treatment and procedures. In these cases, the parent or guardian of the child must give consent on the minor’s behalf.

Is a patient considered competent?

In order to give his or her informed consent, a patient must be competent. Generally, adults are presumed to be competent. However, this presumption can be challenged in cases of mental illness or other impairments. Minors, unlike adults, are generally presumed to be incompetent.

What is the failure to use ordinary care?

Negligence is the failure to use ordinary care, that is, failure to do that which a health care provider of ordinary prudence would or would not have done under the same or similar circumstances. One of the main issues in this case was documentation.

What temperature was the patient's fever during his 3 day hospital stay?

The patient had a fever of just above 100 degrees every day during his 3-day admission, including the day of discharge. According to the cardiologist, but not documented in the patient's medical record, the patient declined cardiac catheterization and wanted to be discharged home.

What age did a patient have a myocardial infarction?

A patient had a long-standing history of coronary artery disease, suffering his first myocardial infarction (MI) at age 47. He had recurrent chest pain a year later and underwent a work up to rule out MI. He was treated medically without invasive procedures. Four years after the first MI, he came to a new cardiologist, the defendant in this case.

What is prudent practice?

Prudent practice involves comprehensive documentation. As with the informed consent process, informed refusal should be documented in the medical record. In the case study, the jury found in favor of the plaintiffs when faced with a deceased patient and an undocumented patient decision of great importance.

What is informed refusal?

INFORMED REFUSAL. Texas law recognizes that physicians must obtain consent for treatment and that such consent be "informed.". A variant of informed consent is informed refusal, in which a patient refuses treatment after having been informed of the risks and benefits of the intervention. Many physicians associate the concept ...

How much did the jury award in the case of the syringe?

The jury found the physician negligent and awarded damages of approximately $50,000 for funeral costs, medical expenses, and past mental anguish.

Can refusal to consent to a recommended intervention lead to a lawsuit?

However, as the case study illustrated, a patient's refusal to consent to a recommended intervention can occur under a variety of circumstances, and can lead to lawsuits involving allegations of failure to treat or failure to inform. "Implicit in and intrinsic to the concept of consent for treatment is the option of refusal.

What happens if you are not educated about your treatment?

If this negligence caused you to suffer financial damages, you could be entitled to recover compensation for these damages through a medical malpractice claim. To learn more, contact our team at Baizer Kolar, P.C. today to set up your initial consultation in our Chicago office.

Is failure to disclose medical information a malpractice?

Failure to disclose any relevant information about a medical procedure is an act of medical malpractice because it robs the patient of the ability to provide his or her informed consent to the procedure. Patients have the right to know what is being done to their bodies and why. They also have the right to decide not to undergo a specific medical treatment, which is a determination frequently made after weighing the risks and benefits of the procedure.

What is the obligation of a physician to obtain informed consent?

The corresponding obligation on the part of the physician is to obtain voluntary informed consent when a patient is to be subjected to surgery and, increasingly, to some nonsurgical interventions as well.

What is the treatment for denervation?

Treatment typically includes dietary and environmental modification, prophylactic medications, analgesics, and, more invasively, chemical or surgical denervation procedures. The combination of diet, prophylaxis, and analgesic is reasonably effective for the majority of patients, but not for all [2-4].

Is migraine a radiological diagnosis?

There are no reliable diagnostic markers or radiological findings. Nevertheless, in the United States, almost every patient who reports migraine headaches is subject to neuroimaging studies (CT or MRI) at some point, if only to exclude an underlying vascular lesion, space-occupying mass, or other treatable pathology.

What to do if a patient cannot be reached?

Health care organizations can do the same. If the patient cannot be reached by the available contact information, try other means including online sources as warranted by the clinical importance of contacting the patient. Assess how reliably individual patients are likely to be contacted and customize your approach.

Why should medical records be documented?

Whatever is done should be documented in the medical record for the usual reasons: to communicate to others what has been done and to provide written or electronic documentation in case the failure to contact becomes the subject of a lawsuit.

What is malpractice standard of care?

The malpractice standard of care requires an effort to contact patients about abnormal test results that is proportionate to the harm that might occur without proper follow up. Two steps that could reduce the harm from failure to contact patients about abnormal test results are engaging patients in following up on pending tests ...

Did the ultrasound technician notice the abnormal test result?

The ultrasound technician did not notice the abnormal test result or the fact that the chlamydia infection had not been treated. The following day, a different OB/GYN clinic nurse tried to call the patient with the ultrasound results, and again no one answered the phone.

What is the purpose of documentation?

Remember, the purpose of documentation is to communicate with other members of the health care team. (If you are the only person who can read your handwriting, your documentation won’t communicate anything to anybody!)

How often should you document vitals?

 Patients in acute care settings tend to be quite sick. If you are ordered to document vital signs every four hours, it’s important to take the vitals—and document the results—on time.

Do Medicare clients need to bathe?

 Home health clients on Medicare must be homebound—and must need help with bathing— to receive the services of a home health aide. Your documentation should show that your client meets these requirements. However, if your client has already bathed when you arrive, document the reason and tell your supervisor right away.

Informed Consent

Special Cases: Competency

Unauthorized Treatment

Find Out If You Have A Valid Malpractice Claim

Case Study

Informed Refusal

The Process of Informed Refusal

Assessing Decision-Making Capacity

Documenting Informed Refusal

Other Risk Management Considerations

• If a doctor fails to obtain informed consent for non-emergency treatment, he or she may be charged with a civil offense like gross negligence and/or a criminal offense such as batteryor gross negligence which is the unauthorized touching of the plaintiff's person. In a civil suit, the patient would have to show two elements. Medical treatment could...

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