Good Practice Tips to Combat the Plaintiff Themes: Documentation of Communications with the Treating Physician

A constant plaintiff theme is to attempt to demonstrate that com­munications between a resident’s treat­ing physician and the nursing home staff failed. Plaintiff’s counsel routinely makes the argument that nursing home nurses are the “eyes and ears of the phy­sician” who is not present 24 hours a day in a nursing home. Plaintiff’s coun­sel will often schedule the deposition of a treating physician and inquire as to whether the nursing home staff timely made the physician aware of an issue or if the physician would have liked to have been made aware of an issue. Plaintiff’s counsel is hoping that, in an effort to avoid being sued, the treating physician will turn on the facility and testify that he/she was not timely notified or would have liked to have been notified of an is­sue by the nursing home staff.

In order to assist with the de­fense against this type of testimony, the facility must establish a system to en­sure timely communication between the facility staff and the resident’s treating physician. Adequate documentation in the Nurse’s Notes or Interdisciplinary Progress Notes of a resident’s daily con­dition is essential in defending this issue. The most common scenario where this issue plays out is when there is little or no documentation in a resident’s chart and then suddenly there is documenta­tion of a change in condition. Without prior documentation confirming that the resident was status quo just prior to the change in condition, it is difficult to es­tablish that the resident’s treating physi­cian was timely notified of a change in condition.

If there is a change in a resi­dent’s condition, the Nurse’s Notes or Interdisciplinary Progress Notes should descriptively document the following: the resident’s condition just prior to the change in status; the time the change in status occurred; any and all nursing as­sessments conducted; the time when the treating physician was notified; a summary of the information that was provided to the physician; receipt and implementation of physician orders; follow-up assessments; and if the phy­sician is not available, and the situation warrants it, the time when 911 was con­tacted and arrived at the facility.