Case Management Focus: You are Summoned!

Sarasota, FL (WorkersCompensation.com) -- A few weeks ago, I discussed the importance of documentation for all case managers. In this post, I wanted to share the importance of documentation if you are ever subpoenaed in a deposition to defend your work.

I was subpoenaed once in a medical malpractice case. It was terrifying and taught me an important lesson. We have all heard this phrase through our years as nurses – “if it wasn’t written – it wasn’t done.

In the deposition, the plaintiff's attorney asked me several questions, and with each answer, he asked me to find the information in the documentation I was required to do as part of my job. We (the Defense Attorney and I) could see most of the information, but there were some questions I needed help finding.

The attorney repeated over and over weren't you supposed to document your work? I would answer him the same each time he asked. Yes, I was, but I need help finding the information in the documentation he brought for me to review.

It was an eye-opening experience and one that I will never forget. I promised myself that I would improve my documentation. I have improved, but I could be better, and I know I have done things for patients that should have been documented that were not due to time restraints and other reasons.

Here are some tips that might help you going forward.

• If you receive a subpoena, contact your supervisor, who will put you in touch with a risk manager and assign an attorney to guide you through the document when you do the work. If you have your Malpractice Insurance, contact them.
• Make notes if you need more time to document right away. Note dates/times and what happened
• The reason for your documentation is to help you remember what you did. Most malpractice cases occur 2-3 years after an event. Most of us don’t have that kind of memory, so documentation is critical.
• Know your employer's policies and procedures for documentation and follow them. Not following these policies can cause your employer not to provide liability insurance.
• This is one of the reasons many nurses get their medical malpractice insurance to ensure they have the coverage and not depend on the employer.
• If an event happens, notify your supervisor as to what happened. Have the supervisor notify your company’s risk manager or in-house attorney. They will open an investigation to get details of the event early on in case of a lawsuit.
• Do not change your documentation once you write it. If you notice something missing, make a note (late entry) and add the information. If you wrote something you feel was a mistake, write a note that you are correcting. Again, if you have a risk manager or in-house counsel, bring this to them and see what they suggest you do.
• Keep a copy of your notes so you have them.

• As nurse case managers, we have Standards of Care to follow. Know the standards and how they apply to you. They are:
  • Case Management Society of America Standards of Practice: https://cmsa.org/sop22/
  • Nurses who work across state lines need to know the rules/laws in each state they work/or the patients they work with. They may even need a license for that state. Here is a link to learn more https://www.ncsbn.org/nursing-regulation/licensure/nurse-licensure-guidance.page .
  • The American Nurses Scope and Standards of Practice: https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf

I hope you never get called in front of a court of law – the best advice is to be prepared.

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