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Full Table of Contents
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Abbreviated
Table of Contents
Home Page
Patient Safety
Silence vs
Safety
Silenced
White wall
of Silence
Silencing
Conflict Of
Interest
Psychology of
Providers
Subjectivity
Blacklisting
Nurse survey
Loyalty
Mobbing and
bullying
Trust Us
Defensive
documenting
Report Rate
Risk
managemnt
SOAP
Management
Hospitals
Crime in
medicine
Sexual Abuse
Liability
Limitations
Free Speech
for Patients
Exploitation
OSMB Medical
Boards
Mammography
solutions
Medical errors
Medical Complaints
One number
Links
Injured patients who want to help and be heard,
click here.
Thomas Jefferson said that given the choice between
government without newspapers and newspapers without government, he would choose
newspapers.
In medicine we have government without newspapers. Patients
cannot find out what they need to know to make informed choices. No one in
medicine records or reports the information patients need to know the most. So
patients will have to do it.
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Notes 2
These are notes linked to from other pages on this site
Linked to from defensive
documentation
risk-reduction
techniques
It is taught and re-taught at every level of medicine, sometimes under the label
of "defensive documentation" sometimes as "risk-reduction techniques" or under
other labels, and always with the understanding that a chart is a legal
document. Patients who understand what is normal will be in a better position to
realize when something about their care is not.
Theses are notes on recommendations from The American
Academy of Family Physicians, one of the largest national medical
organizations, on defensive documentation for physicians.
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To reduce risk, thoroughly document advice and instructions
given to patients.
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A note that summarizes the thought process that led to a
diagnosis is more defensible than a note that simply names the diagnosis.
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A common problem causing suits is physicians' failure to
follow through on tests recommended to patients.
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Failure to document a reasonable effort to rule out certain
problems and clearly explain follow-up plans are pitfalls that lead to
lawsuits.
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Failure to follow up on abnormal results and order
appropriate diagnostic tests are among the problems associated with
malpractice suits.
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Attorneys representing patients often point to physicians'
failure to order tests when nonspecific symptoms are present.
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Notes should be legible.
SOAP
The model evaluation sheet doctors use in charting patients is called SOAP
(Subjective, Objective, Assessment and Plan). It
includes:
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Subjective: The information given to you by the
patient. Use direct patient quotes to demonstrate your attention.
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Objective: Measurable data. Supportive, reproducible
observations.
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Assessment: Your appraisal of the patient's
progress, not only since the last appointment but an overall impression as
well.
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Plan: How you intend to proceed. Include a brief
rationale on why. What do you plan to accomplish with this plan?
It is important for patients to know where to find the above
information when they need it. Otherwise they can be easily and completely
manipulated, even to the extent of being blacklisted
from getting treatment, a concept with which every patient must have at least a
passing familiarity if we are to make any progress in patient safety.
Linked to from home page
Correction to the syndicated
column
The article says that when employees from the hospital became aware of this site
they told me to remove it, and that when I refused, they sued. They didn't tell me to remove it. No one ever contacted me about that. And they didn't "discover" it. I wrote to the CEO of their
corporation about it. I also wrote to a doctor in the hospital, a colleague of
the offending surgeon, and told him about it (I was the victim of XXXX-XXXXX and XXXXXXXX and no one was paying attention to my complaints). But no one contacted me. If they had I would have worked with them to see if we could reach an
accommodation. They abruptly went to court to get an injunction without giving me
enough notice to get representation (the next morning).
I appeared in court alone and told them that I could be easy to get along with if only they would tell me what their problem was with my site. They wouldn't discuss it. A far cry from anyone's having contacted me and having me be the one who was unwilling. It was the reverse. The false claim was
repeated in the next column.
Why aren't security cameras in operating rooms to increase
learning about problems
unless ignoring problems saves hospitals from paying for solutions?
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