Read the “Questionable Medical History Conducted Case Study,” located in Chapter 10 of the textbook. You are a health care administrator and have come across a case study from a community hospital. In order to prevent this incident from occurring in your practice setting, prepare a 10-15 slide PowerPoint educational presentation for your staff. Include the following in your presentation:
- Describe the ethical issues and principles that were violated in this case.
- Describe the potential legal issues of concern.
- What tools or resources should this organization pursue in order to ensure high quality history and physical (H&P)?
- Explain whether negligence has occurred in this case.
- Explain which requirements meet the criteria for determining negligence in court.
- Describe how this situation can be prevented in your practice setting.
QUESTIONABLE MEDICAL HISTORY CONDUCTED
Smith was admitted to Community Hospital for surgery. Community Hospital medical staff bylaws require that a history and physical (H&P) exam be completed prior to patients undergoing surgery. Smith’s attending physician did not complete the H&P form. He simply drew a diagonal line from the top right to the bottom left of the H&P, indicating that the patient had no history of or current disease processes.
The patient’s nurse, per hospital policy, completed a nursing assessment. The nurse documented on the patient admission assessment form that the patient had a history of transient ischemic attacks, diabetes, and hypothyroidism.
The anesthesiologist did not perform an anesthesia assessment before surgery. General anesthesia was administered without knowing the patient’s previous experiences, if any, with anesthesia.
Failure of the attending physician to complete an appropriate H&P examination and the anesthesiologist’s failure to perform a pre-anesthesia assessment placed the patient’s life and health at risk. The physician did not complete the H&P. He merely went through the motions of completing an H&P examination because it was mandated that the patient have an H&P in his medical record prior to surgery.
Ethical and Legal Issues
Discuss the ethical issues and principles violated in this case.
What are the potential legal issues of concern in this case?
Discuss what actions the organization should consider to improve the quality of H&P documentation.
Failure to obtain an adequate patient history and physical examination violates the standard of care owed to the patient. In Foley v. Bishop Clarkson Memorial Hospital,25 Mr. Foley sued the hospital for the death of his wife. During her pregnancy, the patient was under the care of a private physician. She gave birth in the hospital on August 20, 1964, and died the following day. During July and August, her physician had treated her for a sore throat. Several days after her death, one of her children was treated in the hospital for a strep throat infection. There was no evidence in the hospital record that the patient had complained about a sore throat while in the hospital. The hospital rules required that an H&P had to be written promptly (within 24 hours of admission). No history had been taken, although the patient had been examined several times in regard to the progress of her labor. The trial judge directed a verdict in favor of the hospital. On appeal, the appellate court held that the case should have been submitted to the jury for determination. A jury might reasonably have inferred that if the patient’s condition had been treated properly, the infection could have been combated successfully and her life saved. It also might have been reasonably inferred that if an H&P had been taken promptly when she was admitted to the hospital, the throat condition would have been discovered and hospital personnel alerted to watch for possible complications of the nature that later developed. Quite possibly, this attention also would have helped in diagnosing the patient’s condition, especially if it had been apparent that she had been exposed to a strep throat infection. The court held that a hospital must guard not only against known physical and mental conditions of patients but also against conditions that reasonable care should have uncovered.
Patient diagnosis refers to the process of identifying a possible disease or disease process, thus providing the physician with treatment options. Screens, assessments, reassessments, and the results of medical diagnostic testing such as electroencephalography (EEG), electrocardiography (ECG), imaging (FIGURE 10-3), and laboratory findings are some of the tools of medicine that assists providers (e.g., physicians, osteopaths, dentists, podiatrists, nurse practitioners, physician assistants) in diagnosing the possible causes of a patient’s symptoms and medical problems—that is, the medical diagnosis—from which a treatment plan is developed. The cases presented here describe some of the lawsuits that have occurred due to misdiagnoses and failure to properly treat the patient based on the results of diagnostic testing.