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Charting Not Specific: Hospital Not Able To


Defend Against Malpractice Allegations.
uring a lengthy stay in the hospital gress, beginning on the day she was ad-
for medical and surgical treatment, Saying that a patient was mitted to the hospital and continuing
the patient developed a foot drop. throughout her entire stay. The nurses
The foot drop was due to contracture of
monitored appropriately is followed the orders delivered to them by
the Achilles tendon, a complication some- useless without chart notes [the patient’s] treating physicians and
times to be expected if adequate measures of the specific actions that performed their nursing obligations con-
are not taken to compensate for a patient’s constituted monitoring of sistent with these orders. The nurses per-
prolonged immobility, according to an the patient’s condition. formed their duties in an organized fash-
opinion recently handed down by the ion, prioritizing their care and treatment
To defend in court against
Court of Appeals of Texas. objectives and giving due emphasis to task
The patient and her husband sued the professional malpractice, it having the highest priority, while perform-
hospital for negligence. The nurses and is not good enough to gen- ing both high-priority and low-priority
physical therapists who cared for the pa- eralize about the standard of tasks in a timely and appropriate ma n-
tient were employees of the hospital. The care having been met. ner.”
treating physicians were also named as The lower court judge took this affida-
An expert witness must be
defendants in the suit. vit as adequate proof the hospital’s nurses
The hospital, in its defense, submitted able to find in the chart what had not been negligent, and the lower court
affidavits to the court from a nurse and specific examinations and threw out the case. The Court of Appeals
from a physical therapist who were retained treatments were performed. overruled the lower court and reinstated
after the fact to review the patient’s chart. The affidavit of the hospi- the case.
As to the nursing care the patient had tal’s nursing expert witness The Court of Appeals ruled the lower
received, the hospital’s affidavit stated: court judge was in error for failing to recog-
“The standard of care for treating a
contained nothing specific nize that the hospital’s affidavit about the
critical care patient such as ... is (1) to from the chart. The affidavit nursing care the patient received was
assess the patient; (2) to implement and did not prove that the hospi- purely conclusory. That is to say, the
carry out physicians’ orders; and (3) to tal had followed the legal statement of what the nurses had done was
prioritize care and treatment objectives. standard of care. overly generalized to the point it was com-
The nurses assigned to ... properly as- COURT OF APPEALS OF TEXAS, 1997. pletely useless to any court as the basis for
sessed her condition and charted her pro- a ruling in favor of the hospital.
Without specifying when or how, the
Subscription Information: legal eagle eye newsletter For the Nursing Profession hospital’s affidavit merely stated that the
Published monthly, twelve times per year. Subscription rate $155.00 per year - 12 monthly issues. nurses assigned to the patient “properly
Checks payable to “Legal Eagle Eye Newsletter.” Federal Employer ID No. 91-1636145. assessed her condition.” The hospital’s
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©1997 Legal Eagle Eye Newsletter. ISSN: 1085-4924
affidavit made no reference to any specific
(10/97) charting addressing the monitoring, care
Legal eagle eye newsletter and treatment necessary to prevent the
p.o. box 4592 specific condition, Achilles tendon con-
seattle, wa 98194-0592
tracture, over which the suit was filed, ap-
fax (206) 440-5862 phone (206) 440-5820 E Mail info@nursinglaw.com
e. kenneth snyder, bsn, rn, jd - editor/PUBLISHER parently because no such specific charting
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was anywhere to be found in the patient’s
voluminous medical record.
Name ____________________________________________________________________________________________________________ The court went on to address the spe-
cific individual responsibilities of the medi-
Organization _______________________________________________________________________________________________________ cal doctors, the physical therapists and the
nurses. Their patient-care duties obviously
Street ____________________________________________________________________________________________________________
are different. However, the court believed
City/State/Zip ______________________________________________________________________________________________________
all share a common collective responsibility
to monitor a patient for complications to be
expected during a protracted hospitaliza-
tion. Griffin vs. Methodist Hospital, 948 S.
W. 2d 72 (Tex. App., 1997).

Legal Eagle Eye Newsletter for the Nursing Profession October, 1997 Page 4

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