Discussion Peggy Beeley, MD 2/11/14 Mitigating Medical Malpractice Risks Through Documentation

Creating time lines Document timelines No way to audit what was added to a note when, only see when the note was started and when resident opened files Documentation of Consultation Who was called The time the consultant was called When they returned the call When was the patient seen Verbal recommendations Avoid copy paste of consultants note into team note

Documentation Log

Medical Student Documentation These notes are admissible as evidence Should we not be signing them? Should we be reading every line and correcting them? Consider changing our attestations

T HIS CONFIDENTIAL CORRESPONDENCE I S A TTORNEY - CLIENT PRIVILEGED COMMUNICATION AND CONTAINS HIPAA PROTECTED PATIENT INFORMATION AND / OR ATTORNEY WORK PRODUCT PROTECTED INFORMATION The Office of the University Counsel (“OUC”) has received a Tort Claims Notice from the patient referenced above and in the attached notice. A Tort Claim notice is the required notice of a potential lawsuit that must be filed with a state. Being a recipient of this correspondence does NOT mean that you are a defendant, that you have been named in this claim, or that you are being “sued”. You are not named in this claim. You are simply a provider who we identified via a chart audit as accessing this patient’s chart during the relevant time period. Unless you receive further instructions from our office, you do not report receipt of this correspondence to the Credentials Committee or any licensing boards as a claim or lawsuit involving your care. The sole purpose of this correspondence is to ensure that any information you may have regarding this patient that is not in the medical record (i.e. s, hand-written notes, text messages, “shadow files”, etc.) are preserved and provided to our office so that we can comply with relevant state and federal law and judicial orders.

In order for us to comply with our legal obligations regarding data preservation, we need your assistance. If you do not comply with these requests in this memo and documents are lost, we could face serious problems in defending ourselves in this litigation. This is a matter the courts take very seriously. To comply, please do the following:  Please limit your written and electronic communications regarding this patient to what is necessary for continued treatment (if applicable), quality assurance, and compliance with the directions in this correspondence.  You may access the medical record to refresh your memory about this patient. Please do not make any changes or additions to the medical record that are not related to patient care. Please limit your review of the record to the minimum necessary to refresh your recollection about your involvement in this patient’s care.  Unless it is for medical care or quality assurance, please do not talk with anyone about this patient as those conversations are not privileged and would have to be disclosed to the patient’s attorney.  Please preserve all documents, samples, specimens, electronically stored information, and any other responsive information regarding the above-referenced patient.  Please take precautions to avoid destruction or alteration of these documents.  Please put these documents someplace secure in your Department and contact our office to arrange for copies to be received, and  Finally, once you complete your search, please sign and return the attached certification along with any responsive documents to Chamiza Pacheco de Alas via fax (505) or or delivery at HSSB, room

Search CompletedLocation Local Area Server for my office Personal Partition or Personal Folders on Server Dedicated Server for __________Department Laptop and/or Office Computer Home Computer, Blackberry and/or PDA , including archived and sent Removable Storage Media, such as discs, CDs, DVDs, Memory Sticks, and thumb drives Office Files/Department Files Personal Desk Files Files of any Administrative Personnel working for me Files located in my home Certification to the Office of University Counsel MSC &/or FAX (505) This certification must be returned to Chamiza Pacheco de Alas, Associate University Counsel, even if you do not have any responsive material. I have read the attached Memorandum and have conducted a reasonable search for any responsive documents. I certify that since receiving notice from UNM’s Office of University Counsel to retain all documents electronic or otherwise regarding Mr XXXXX, MRN: xxxxxand issues pertaining to the patient’s medical treatment. I hereby certify that I have searched the following locations for responsive documents and have checked any that are applicable to locations where such responsive documents may be stored. I hereby further certify have not altered, discarded, or destroyed any responsive documents in either paper or electronic form. (Please check all boxes as appropriate) ________________________________Date__________________________