Whether you’re representing the plaintiff or the defendant, the hospital chart is the single most important source of information about the viability or defensibility of a medical negligence claim.
The necessary elements of proof of a claim for negligence of a health care provider are described in ARS §12–563:
- The health care provider failed to exercise that degree of care, skill and learning expected of a reasonable, prudent health care provider in the profession or class to which he belongs within the state acting in the same or similar circumstances.
- Such failure was a proximate cause of the injury.
Medical negligence claims for care provided in a hospital pose unique challenges for plaintiffs, defendants and their counsel. A hospital chart is a comprehensive record of the care provided, the reasons for the care, and a record of the patient’s response to the care. Patients in hospitals are cared for by many nurses, physicians and others. Every important observation of the patient is recorded in the chart. Physician orders, requests for specialty consultations, the consultant reports, blood work, lab work, imaging studies, and results of all other diagnostic and therapeutic interventions are recorded in the chart. By the same token, as a general rule, if something isn’t in the chart, as a rule of thumb, it did not happen.
Understanding the chart requires an understanding of how it is organized.
Hospital charts are organized both chronologically and in sections based upon the type of information (progress notes, physician orders, nursing progress notes, medication administration records, vital sign flow charts, etc.); the type of health care provider generating and recording the information, (nurse, physician); and the type of information (laboratory, bloodwork, metabolic studies, x rays, etc.).
The notes from a given shift (typically 12 hours) are used to communicate information about the patient’s condition from earlier points in time to caregivers who become involved afterward.
There are entries from doctors, nurses, specialty consultants and potentially a host of others who care for the patient in the hospital. Many are handwritten. In fact, the handwritten notes often provide the most timely and important information about a patient’s condition. The typed consults of specialists, for example, are first handwritten into the patient’s chart at the time the specialist sees the patient. The dictated and transcribed consultation notes aren’t put into the chart until they are complete, which is often days later, and can happen after the patient is discharged.
The chart allows caregivers to identify the people who have cared for the patient throughout the hospitalization. The chart is how the caregivers communicate with each other about a patient. It serves the same purpose for lawyers trying to determine the caregivers after the fact.
Normal vital signs charted two minutes before the patient is found not breathing and unresponsive, suggests the patient could not have been unresponsive for more than two minutes. That may be important in determining if anything could reasonably have been done to revive the patient.
Inconsistent chart entries by different people at approximately the same time can be harmonized or explained by other entries in the chart. For example, if a physician describes a patient as doing better, appears excited to go home, will likely discharge home later this afternoon, at approximately the same time a nurse charts, patient lethargic, slow speech and flat affect, appears depressed. It is not likely both descriptions are accurate. If the vital signs recorded at the time are normal, it is less likely the nurse’s observations are accurate. If the patient’s respirations at the time are abnormally slow or are described as irregular, it is less likely the patient looks as described by the doctor.
Hospitals have written policies, procedures, nursing protocols and standing orders for what information is recorded, how it is recorded, and what information is required before a given therapy or diagnostic study can be performed. Those rules provide a framework for determining what information should be in the chart.
The importance of the hospital record is addressed in employee orientation programs. It is the subject of nursing job performance evaluations and adequate hospital standards regarding information management, covered by the JCAHO hospital accreditation standards, which must be complied with by a hospital to obtain a license to operate in Arizona.
As a practical matter, the presence or absence of an entry in the patient’s hospital chart often is an essential factor in assessing the viability of a medical negligence claim. As an example, patients are discharged from the hospital with a set of written instructions. Typically, the instructions are discussed with a nurse before the patient leaves the hospital. If the nurse testifies she told the patient to return if not better in two days, but that instruction is not in the written document, the plaintiff ’s claim that he wasn’t told to do so is more supported.
The importance of the hospital chart cannot be overstated. This article barely touches the surface of the topic. If you have questions about a hospital chart in one of your cases, please reach out to me.