Problem: DOCUMENTATION ISSUES
Smith was admitted to Community Hospital for surgery. The hospital's policy requires that history and physical examinations be completed prior to patients' undergoing surgery. Smith's attending physician did not complete the form. He simply drew a diagonal line from the top right to the bottom left of the history and physical form, indicating that the patient had no history of or current disease processes. The patient's nurse, per hospital policy, completed a nursing assessment. The nurse documented on the patient admission assessment form that the patient had a history of transient ischemic attacks, diabetes, and hypothyroidism. The anesthesiologist did not perform an anesthesia assessment before surgery. General anesthesia was administered without knowing the patient's previous experiences, if any, with anesthesia. Failure of the attending physician to complete an appropriate history and physical examination and of the anesthesiologist to perform a preanesthesia assessment placed the patient's life and health at risk. The physician did not complete the history and physicals. He merely went through the motions of completing a history and physical examination because it was mandated that the patient have a history and physical in his medical record prior to surgery.
Ethical and Legal Issues
1. Discuss the ethical issues and principles violated in this case.
2. What are the potential legal issues of concern in this case?
3. Discuss what actions the organization could take to improve the quality of history and physical documentation.