Explain the four elements of negligence that must be present in order for a plaintiff to recover damages?
Discuss the purposes for which the health record is maintained within a healthcare organization.
Explain the concept of e-discovery and discuss the role of health information management professionals in the e-discovery process.
What are the differences between a living will and a durable power of attorney for healthcare?
The corporate director of risk management is asked to review a patient’s health record in preparation for legal proceedings for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being non-compliant with the organization’s record completion policies, and previous concerns regarding this physician’s record maintenance practices had been reported to the organization’s credentialing committee.
1. Apply appropriate legal concepts to demonstrate why this health information may not be admissible in court.
2. What judgment, if any, regarding negligence could be made against the organization?

SOLUTION

1. Four Elements of Negligence

For a plaintiff to recover damages in a negligence case, four elements must be proven:

Duty of Care – The defendant (e.g., physician or hospital) must owe a legal duty to the plaintiff. In healthcare, this typically arises once a provider-patient relationship is established.
Breach of Duty – The defendant must have failed to meet the standard of care expected of a reasonably competent professional in similar circumstances.
Causation – The breach of duty must be directly linked to the injury. This is divided into actual cause (“but for” the negligence, the harm would not have occurred) and proximate cause (the harm was a foreseeable result).
Damages – The plaintiff must demonstrate actual harm, such as physical injury, emotional distress, financial loss, or loss of quality of life.

Without all four elements, negligence cannot be legally established.

2. Purposes of the Health Record

The health record serves multiple purposes within a healthcare organization, including:

Clinical Care: Provides continuity of care by documenting diagnoses, treatments, and outcomes.
Legal Documentation: Serves as evidence in legal proceedings, including malpractice cases.
Regulatory Compliance: Demonstrates compliance with standards set by accrediting and regulatory bodies.
Billing and Reimbursement: Supports claims for insurance and government payers.
Research and Education: Supplies data for clinical research, quality improvement, and training future healthcare professionals.
Risk Management: Helps identify trends and prevent medical errors.

3. E-Discovery and the Role of Health Information Management (HIM) Professionals

E-discovery refers to the process of identifying, collecting, preserving, and producing electronically stored information (ESI) for use in litigation or regulatory investigations. In healthcare, this includes electronic health records (EHRs), emails, audit trails, and metadata.
HIM professionals play a critical role in e-discovery by:

Ensuring data integrity and accuracy.
Applying retention and destruction policies consistent with legal requirements.
Coordinating with legal teams to produce records that are complete and admissible.
Protecting patient privacy and HIPAA compliance during the discovery process.

4. Living Will vs. Durable Power of Attorney for Healthcare

A Living Will is a legal document that specifies an individual’s preferences for medical treatment in end-of-life situations, such as resuscitation, ventilator use, or artificial nutrition. It only takes effect if the patient is incapacitated and unable to communicate.
A Durable Power of Attorney for Healthcare (DPOA-HC) designates a trusted person (healthcare proxy) to make medical decisions on behalf of the patient if they become incapacitated. Unlike a living will, it allows flexibility in responding to medical situations not explicitly outlined in advance.
Key difference: A living will outlines treatment preferences, while a DPOA-HC empowers someone to make decisions.

5. Admissibility of Health Information in Court

In the malpractice case described:

The health information (procedure summaries) was dictated 95 days after the procedure, long past normal completion timelines.
Courts generally consider contemporaneous records (those completed at or near the time of care) more credible. Records created or altered long after the fact may be challenged as inadmissible because they lack reliability and may appear self-serving.
The physician’s history of non-compliance with documentation policies further undermines credibility.
Under the Federal Rules of Evidence and comparable state rules, late or inconsistent records may be excluded as hearsay or due to questions about authenticity and trustworthiness.

Thus, these records may not be admissible because they fail to meet legal standards for reliable, contemporaneous documentation.

6. Judgment Regarding Negligence Against the Organization

The organization could face negligence claims based on corporate liability and negligent credentialing:

Corporate Negligence: Hospitals have a duty to monitor and ensure that providers comply with policies, including timely documentation. Allowing persistent non-compliance may constitute a breach of that duty.
Negligent Credentialing: Since prior concerns about the physician’s record-keeping were reported to the credentialing committee, the organization may be liable for failing to act on these warnings.
Vicarious Liability (Respondeat Superior): The organization may also be held indirectly responsible for the actions of its employee or affiliated physician.

If proven, the organization could share liability with the physician for harm caused by delayed or inadequate recordkeeping, particularly if this documentation failure affects the patient’s ability to receive proper care or pursue legal remedies.

The post Legal and Ethical Dimensions of Negligence and Health Information Management appeared first on Skilled Papers.