CASE 2-2 Alteration of Patient Record : A patient was admitted to the hospital\'

Question

CASE 2-2 Alteration of Patient Record : A patient was admitted to the hospital's ambulatory surgery unit for surgical removal of four impacted wisdom teeth. As required, a staff internist did a history and physical (H&P;) examination prior to admission. The dental : surgeon removed the wisdom teeth and administered penicillin intramuscularly as a prophylactic. The patient : had an immediate and violent reaction to the penicillin. After an extensive stay in the intensive care unit (ICU), : the patient was discharged On routine discharge analysis, the health information management (HIM) clerk found several deficiencies requiring physicían completion. During this analysis of the record, the clerk observed that the H&P; stated o known allergies. As she was filing the ambulatory surgery record in the patient's file folder, she noticed that the previous encounter had ALLERGIC TO PENICILLIN stamped in red letters on the visit's cover sheet. She placed the record in the incomplete chart area for completion. : When reanalyzing the chart a few days later, she saw that the H&P; had been altered to read patient denies : any drug allergies. While no one saw the alteration being made, the chart had been pulled for the dental : surgeon. She took the record to the HIM director, who called the hospital attorney. The patient filed a malpractice suit a few months later 1. Identify the issues involved in this situation. 2. Recommend a process to be implemented to prevent this problem from happening again.

Explanation / Answer

Identifiy the issues involved in this situation:

The issue of this case is = Medical malpractice

Medical malpractice is characterized as any demonstration or oversight by a doctor amid treatment of a patient that goes astray from acknowledged standards of training in the medicinal group and makes damage the patient. Restorative misbehavior is a particular subset of tort law that arrangements with proficient carelessness

Recommend a process to be implemented to prevent this problem from happening again:

Here are the strategies to prevent malpractice:

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