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What PTs need to know to Avoid a Lawsuit

CombinedSectionsMeeting2015

February 4‐7, 2015

Indianapolis, IN

www.aptahpa.org HPA The Catalyst is the Section on Health Policy & Administration

of the American Physical Therapy Association

Speaker(s): Michael Loughran, BA

Sheila K. Nicholson, PT, DPT, Esquire, MBA, MA

Session Type: Educational Sessions

Session Level: Multiple Level

This information is the property of the author(s) and should not be copied or otherwise used without the

express written permission of the author(s).

of 39 total pages

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What PTs Need to Know to Avoid a Lawsuit

Michael LoughranPresidentHealthcare Providers Service Organization (HPSO)

Sheila K. Nicholson, Esq., DPT, MBA, MA, PTPartnerQuintairos, Prieto, Wood & Boyer, P.A.

February 7, 2015

American Physical Therapy AssociationCombined Sections Meeting 2015

Michael LoughranSheila Nicholson


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DisclaimerThe purpose of this presentation is to provide general information, rather than advice or opinion. It is accurate to the best of the speakers’ knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional and legal counsel. In addition, CNA, Aon, Affinity Insurance Services, Inc. (AIS), Nurses Service Organization (NSO) or Healthcare Providers Service Organization (HPSO) do not endorse any coverage, systems, processes or protocols addressed herein unless they are produced or created by CNA, AON, AIS, NSO, or HPSO, nor do they assume any liability for how this information is applied in practice or for the accuracy of this information.

Any references to non-CNA, non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and CNA, AON, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. To the extent this presentation contains any descriptions of CNA products, please note that all products and services may not be available in all states and may be subject to change without notice. Actual terms, coverage, amounts, conditions and exclusions are governed and controlled by the terms and conditions of the relevant insurance policies. The CNA Professional Liability insurance policy for Nurses and Allied Healthcare Providers is underwritten by American Casualty Company of Reading, Pennsylvania, a member of the CNA group of underwriting companies. CNA is a registered trademark of CNA Financial Corporation. © 2015 CNA Financial Corporation. All rights reserved.

NSO and HPSO are registered trade names of Affinity Insurance Services, Inc., a unit of Aon Corporation. Copyright © 2015, by Affinity Insurance Services, Inc. All rights reserved.

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Today’s Speakers

Michael LoughranPresident, Healthcare Providers Service Organization (HPSO)

Sheila K. Nicholson, Esq., DPT, MBA, MA, PTPartner, Quintairos, Prieto, Wood & Boyer, P.A.

Disclosure Statement: All speakers in a position to control the content of this activity have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity with the extent of their participation in the activity.



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Presentation Objectives

• Identify current professional liability claim trends for physical therapists in

malpractice lawsuits.

• Identify reportable incidents which may lead to malpractice lawsuits and

discuss the importance of good documentation. Identify what information to

include in incident reports and how to maintain patient confidentiality.

•Discuss selected physical therapist claims and factors which may contribute to

malpractice lawsuits. Identify key risk management recommendations to

support physical therapists in managing their risk which they can incorporate

into their practice.

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Who is HPSO?• Healthcare Providers Service Organization (HPSO) provides professional

liability insurance to healthcare professionals, to 80+ professions, including PTs and private practices.

• We insure over 59,000 individual PT customers, with more than 9,000

private practices (approximately representing an additional 35,000 PTs and

PTAs).

• HPSO is committed to helping physical therapists better understand their

liability risks in order to provide better patient outcomes and reduce the

possibility of a suit.

• We produce and post on the HPSO website legal case studies, risk

management articles, newsletters as well as claim reports.



CLAIM METRICSPT

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Claim Metrics for Physical Therapists

Nationwide View

Data 01.2010 thru 10.2014 as of November 2014

COUNT PAID RESERVE EXPENSE TOTAL

Open 362 200,531$ 17,398,695$ 3,929,789$ 21,529,014$

Closed with No Payment 1739 $ - $ - $ - -$

Closed with Payment 619 $ 43,096,040 $ - $ 13,540,187 $ 56,636,227

Closed Expense Payment Only 577 -$ -$ 7,167,711$ 7,167,711$

Total 3297 43,296,571$ 17,398,695$ 24,637,687$ 85,332,952$



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Claim Metrics for Physical Therapists

Specialty: Nationwide View


COUNT PAID RESERVE EXPENSE TOTAL

Physical Therapist 1340 32,612,515$ 15,714,298$ 17,443,623$ 65,770,436$

Private Practice 162 8,456,288$ 1,127,505$ 6,135,010$ 15,718,803$

Physical Therapy Assistant 56 2,227,768$ 556,892$ 1,059,054$ 3,843,714$

Total 1558 43,296,571$ 17,398,695$ 24,637,687$ 85,332,952$

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Closed Claims with Payment by Coverage Type:Nationwide View

Closed Claims with Indemnity or Expense Payment onlyData 01.2010 thru 10.2014 as of November 2014

COUNT INCURRED AVERAGE

PL w/ Indemnity Paid 577 48% 55,431,445$ 87% 96,068$

PL w/ Expense Only 315 26% 6,049,448$ 9% 19,205$

License Protection 154 13% 733,431$ 1% 4,763$

Deposition Assist 76 6% 196,527$ <1% 2,586$

General Liability 30 3% 998,945$ 2% 33,298$

Personal Injury 13 1% 213,900$ <1% 16,454$

Records Request 10 1% 7,362$ <1% 736$

Medical Payments 9 1% 16,377$ <1% 1,820$

HIPAA 5 <1% 128,373$ <1% 25,675$

Property 4 <1% 18,871$ <1% 4,718$

Assault 2 <1% 8,459$ <1% 4,230$

Defendant Expense Benefit 1 <1% 800$ <1% 800$

Total 1196 100% 63,803,938$ 100%



CLAIM SCENARIOPT

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Case Summary

•After having had her right knee replaced during the prior year, a 70 year

old female underwent total left knee replacement surgery. Two months

post surgery, she injured her left knee suffering a patella avulsion

fracture. She was fitted with a knee immobilizer and one week later had

surgical repair.

•She was discharged home with physician prescribed physical therapy

orders to ambulate in her T-Rom brace and do weight bearing exercise

as tolerated with no range of motion. The orders specified that the brace

was to be worn at all times locked at zero degrees.



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Case Summary

•Therapy orders were received by our insured private practice where the

PT saw the patient and developed a home therapy care plan.

•An employed PTA was assigned and noticed during the first visit that

instead of wearing the T-Rom brace, the patient was wearing her knee

immobilizer. The care plan did not delineate which brace should be used

for therapy, so the PTA did not change the brace.

•The plan also did not include the physician’s orders related to weight

bearing as tolerated. The PTA had the patient stand next to him using

her standing walker, balance on her left operative leg and perform hip

abduction exercises.

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Case Summary

•During weight shifting, the patient lost her balance, was caught by the

PTA and lowered to her chair. The PTA removed the brace and

inspected the knee. The patient reported pain which relieved when

sitting. No bruising was observed.

•The patient was seen by another PTA on 5 separate occasions over the

next 10 days. There are no records of any pain in subsequent patient’s

records.



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Case Summary

•At a follow-up visit with her physician, the patient reported the incident in

which her leg buckled. A surgical repair to the patella alta was

subsequently performed.

•Three months later, the patient was diagnosed with a re-rupture of the

patella alta which required additional surgery.

•A month later, the surgeon performed an allograft reconstruction of her

extensor after which she developed an infection in the wound.

Aggressive wound treatment was undertaken which was unsuccessful.

•The patient then had her leg amputated below the knee. This treatment

was unsuccessful and the patient eventually required further amputation

above the knee.

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• Do you believe that the PTA was negligent?

• Do you believe that any other practitioners or parties were

negligent?

• Do you believe that an indemnity and/or expense payment was

made on behalf of the PTA?

• If yes, how much?

Was the PTA Negligent?



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•PT expert witnesses for the defense were supportive of the care provided by

the PTA. However, they opined that the care plan provided by the PT was

substandard since he did not designate the weight bearing status or

appropriate brace contained in the physician’s orders. Throughout the

deposition and discovery process, no other cause could be attributed to the

patient’s need for her subsequent surgeries.

•Despite having had two total knee replacements, attorneys for the patient

alleged she was a very active 70 year-old at the time of the incident. She

cared for her grandchildren and her husband who was experiencing early

stage dementia. She was also active in her church and community. They

further opined the injury which occurred during her first visit was the single

event leading to the subsequent failed knee replacement, infection, multiple

amputations and loss of former qualify of life.

What The Experts Determined

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•The matter was sent to court ordered mediation where negotiations

subsequently stalled. Eventually, the mediator asked the CNA claim

consultant in attendance to meet alone with the patient and her family. He

felt that hearing directly from the claim consultant would help the patient and

her husband understand the true value of their case. Together, they

discussed the costly effort facing the patient in terms of deposing and

compensating additional expert witnesses with their own money. In addition,

it could not be guaranteed a jury would ultimately rule in their favor or agree

to their settlement value. After this discussion, a mutually acceptable

settlement range was negotiated and the claim settled.




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• Indemnity payment: $550,000

• Expense payment: $69,000

How Much was Paid on Behalf of the PTA?

• Figures represent only the payments made on behalf of the PTA and

do not include any payments that may have been made by the co-

defendants.

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•Properly prepare an appropriate care plan based on the physician’s

prescribed physical therapy orders.

•Discuss with the patient and obtain written confirmation from the

patient the physician’s prescribed physical therapy orders to

assure the patient was aware that any deviation she did from the care

plan could contribute to re-injury.

•Review the physician’s orders prior to providing patient care.

Risk Control Recommendations



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•Know and comply with your facility incident/accident reporting

policy and procedure.

•Notify the supervising or assigned physical therapist or facility

manager of the patient’s injury and document the patient’s

statement “Yes, I’m alright” as evidence that there was no significant

injury at the time of treatment.


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CLAIM METRICSPT

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Claims by Location of Loss: Nationwide ViewProfessional Liability Closed Claims with Indemnity or Expense Payment


Count Incurred Average

Physical Therapy Office/Clinic 740 83% 48,498,109$ 79% 65,538$

Patient's Home 50 6% 4,754,296$ 8% 95,086$

Hospital - Inpatient PT 27 3% 3,547,993$ 6% 131,407$

Aging Services Facility 23 3% 2,195,623$ 4% 95,462$

Rehabilitation Facility 23 3% 886,529$ 1% 38,545$

School 7 1% 791,297$ 1% 113,042$

Practitioner Office/Clinic 11 1% 534,066$ 1% 48,551$

Athletic Field 1 <1% 81,068$ <1% 81,068$

Hospital - Outpatient PT 2 <1% 80,799$ <1% 40,400$

Pool 4 <1% 70,128$ <1% 17,532$

Prison/Correctional Facility 4 <1% 40,986$ <1% 10,246$

Total 892 100% 61,480,893$ 100% 68,925$

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Claims by Primary Allegation: Nationwide ViewProfessional Liability Closed Claims with Indemnity or Expense Payment


Count Incurred Average

Failure to Supervise/Monitor 174 20% 14,748,792$ 24% 84,763$

Improper Performance of Manual Therapy 145 16% 11,610,212$ 19% 80,070$

Improper Management of Treatment 203 23% 11,213,697$ 18% 55,240$

Improper Performance using a Physical Agent 156 17% 5,814,773$ 9% 37,274$

Improper Performance using Therapeutic Exercise 67 8% 5,706,619$ 9% 85,173$

Equipment Related 70 8% 4,214,611$ 7% 60,209$

Failure to Test/Diagnose/Treat 39 4% 3,700,685$ 6% 94,889$

Sexual Misconduct 23 3% 3,205,964$ 5% 139,390$

Delay in Recovery 9 1% 1,098,303$ 2% 122,034$

Improper Performance of Needle Therapy 3 <1% 147,581$ <1% 49,194$

Professional Misconduct 3 <1% 19,656$ <1% 6,552$

TOTAL 892 100% 61,480,893$ 100% 68,925$



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Claims by Resulting Injury: Nationwide View


Professional Liability Closed Claims with Indemnity or Expense Payment

Count Incurred AverageFracture/Dislocation 262 29% 21,660,208$ 35% 82,673$ Increase or Exacerbation of injury/symptoms 106 12% 6,784,841$ 11% 64,008$ Burns 159 18% 5,601,630$ 9% 35,230$ Muscle/Ligament Damage 72 8% 5,102,309$ 8% 70,865$ Disc Injury 39 4% 3,617,894$ 6% 92,767$ Emotional Distress 28 3% 3,241,269$ 5% 115,760$ Death 19 2% 2,954,564$ 5% 155,503$ Sprain/Strain 61 7% 2,794,425$ 5% 45,810$ Amputation 12 1% 2,257,938$ 4% 188,162$ Abrasion/Irritation/Laceration 55 6% 2,159,351$ 4% 39,261$ Neurological Injury 10 1% 1,799,431$ 3% 179,943$ Paralysis 1 <1% 1,060,962$ 2% 1,060,962$ Infection/Abscess/Sepsis 18 2% 708,776$ 1% 39,376$ Bruise/Contusion 31 3% 682,301$ 1% 22,010$ Stroke 3 <1% 492,826$ 1% 164,275$ Loss of Sight/Hearing 4 <1% 150,660$ <1% 37,665$ Brain Injury 3 <1% 146,437$ <1% 48,812$ Loss of Organ/Function 3 <1% 130,567$ <1% 43,522$ Loss of use of limb 3 <1% 124,290$ <1% 41,430$ Disease 2 <1% 9,121$ <1% 4,561$ Cardiovascular Injury 1 <1% 1,093$ <1% 1,093$ TOTAL 892 100% 61,480,893$ 100% 68,925$

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Claims by Distribution of Total Incurred: Nationwide ViewProfessional Liability Closed Claims with Indemnity or Expense Payment

Total Incurred

Claim

Co

un

t Clo

sed P

L O

nly

32%34%

16%

12%

4%1% 0% 1%

0%

10%

20%

30%

40%

50%

60%

<$10,000 $50,000 $100,000 $250,000 $500,000 $750,000 $1,000,000 >$1M




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Time to ClosureProfessional Liability Closed Claims with Indemnity or Expense Payment

Total Incurred

Averag

e Nu

mb

er of M

on

ths fro

m R

epo

rt to C

lose


15

25

31

3740

70

3935

0

12

24

36

48

60

72

<$10,000 $50,000 $100,000 $250,000 $500,000 $750,000 $1,000,000 >$1M

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CLAIM SCENARIOPT

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Case Summary

•The patient was a 49-year old female recovering from a hit and run

motorcycle accident in which she sustained a fracture of the fourth

cervical vertebra, crushed spine and a fracture right wrist.

•Following a 95-day in-patient hospitalization where she underwent

multiple surgeries and was in a coma for several days, she was admitted

to a rehabilitation facility to receive extensive physical and occupational

therapy.

•On admission to the rehabilitation facility, she did not complain of any

pain, but was only able to ambulate using a rolling walker due to muscle

tightness, weakness and sensory deficit to her lower extremities.

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Case Summary

•Our physical therapist examined the patient upon admission and made

note that the patient was morbidly obese and had a long history of both

heavy smoking (two packs of cigarettes a day) and prednisone steroid

use. He recommended a therapy plan based on the patient’s limitations

and goals.

•Five months into her therapy, the patient was performing an exercise

that she had performed many times during her therapy treatments. She

held onto the bars from two machines, one with each hand, stood on her

left leg and had her right foot placed on a round exercise ball. With her

right foot on the round exercise ball, she would move her foot back and

forward in order to engage the muscle of her left hip and improve her

strength and range of motion.



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Case Summary

•Our physical therapist positioned a non-moving chair behind the patient

in the event that she needed to sit down at any time and he sat on the

floor in front of her to assist in insuring the ball did not roll away. During

the exercise, the patient felt weak on her right leg and moved to sit

down; however, her weight was such that she transferred weight very

heavily onto her standing leg and in doing so fractured metatarsal bones

at the top of her left foot. She never fell to the ground, but she

immediately sat down and complained of pain in her foot.

•The patient continued to recover at the rehabilitation facility, participate

in physical therapy and was discharged five weeks after to the fall.

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The patient’s experts made several claims against our insured physical

therapist which included the following:

•The equipment the physical therapist used to have the patient hold onto was

at different heights which created a hazardous environment.

•The physical therapist was on the floor in front of the patient and not behind

to stabilize with a patient who is weak and overweight.

•The parallel bars could have been used for the same exercise which would

have created handholds of the same height which would have led to a more

solid foundation and equal distribution of weight.

Was the Physical Therapist Negligent?



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•The physical therapist should have been guarding the patient by standing

behind her for guidance.

•A gait belt should have been used to prevent a fall.

•The defending attorney asked several experts to review this claim and

received mixed opinions as far as support for the exercise our insured had

the patient perform when she fell.


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•The insured PT was evasive and also untruthful in his answers to some

questions that the defense attorney posed to him during the discovery

phase.

•We learned that while he claimed he did not have any "policies and

procedures" manuals, he actually had three volumes in his clinic.

•We also learned that the insured leaves his clinic open for patients to self-

exercise when no licensed physical therapist is present, which is against

regulations.

•The insured PT was also unable to meaningfully explain how the exercise

was being performed; this may only be due to a language barrier. It was felt

that if this case went to trial, the language barrier would have a negative

impact on the Jury.




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• Do you believe that the PT was negligent?


negligent?


made on behalf of the PT?



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• Indemnity payment: $175,000


How Much was Paid on Behalf of the Physical Therapist?

• Figures represent only the payments made on behalf of the physical

therapist and do not include any payments that may have been made

by the co-defendants. Amounts paid on behalf of the multiple co-

defendants named in the case are not available.



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•Know and practice within your state-specific scope of practice and

standard of care.

•Evaluate the safety of the physical environment in relation to the

patient’s condition and therapy needs prior to each treatment.

•Cease any treatment deemed to present a safety risk to the patient

and contact the supervising physical therapist and/or physician to make

necessary adjustments to the treatment regimen.

•Immediately report and document any patient fall, injury or adverse

event and remain with the patient until medical assistance arrives

and transports the patient, provides direct treatment or declares the

patient is not injured.


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CLAIM SCENARIOPT

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Case Summary

•The insured PT owns a private practice whose specialty is treatment of

orthopedic conditions. Initially, the patient, a 55 year old male, received

physical therapy from our insured PT following his total knee

replacement.

•A year later, the patient was referred to our insured for treatment of his

back pain. Approximately two years later, the patient contacted our

insured to request consultation for his on-going back pain.

•The patient did not have a physician referral, but in light of their past

relationship, the insured agreed to see the patient for a consultation.

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Case Summary

•The patient denied any history of trauma but advised he had been

experiencing severe pain that had been increasing rapidly over the past

several days. He said “he felt like something needs to pop”. The patient

could hardly lift his arms. However he denied any dizziness or

numbness.

•The PT began a very basic spinal examination by having the patient lay

flat on a physical therapy board. The exam took about 2-3 minutes and

the PT recalled palpating from the T-8 to T-4 levels. He began the

process of oscillating the facet joints and when he reached the T-4 level,

began a grade 3-4 test of range of motion.



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Case Summary

•At this point, the patient complained of electrical shock, brief and short.

The patient was then placed in the prone position and upon palpation, it

was noted the patient had severe muscle spasms and reported a

tingling shooting all the way to his legs.

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Case Summary

•The PT quickly stopped the exam and informed the patient he could not

continue further examination because the muscles were too tight. He

recommended that the patient stand up and go to the massage table

where the PT would try a light massage to loosen the muscles and then

continue the evaluation.

•The patient was placed on a massage table with a low setting of 8 pounds.

After 15 minutes, the PT assisted the patient off the table when the patient

began complaining of tingling in his legs. The PT determined that the

plaintiff had a serious neurological issue, recommended emergent

treatment and called an ambulance.

•The patient claims to have lost function of his legs by the time the

ambulance arrived about 15 minutes later.



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Case Summary

•The patient was transported to a nearby medical center where an MRI of

the thoracic spine showed multilevel degenerative disc disease with

mixed protrusions causing various degrees of central canal stenosis.

•The patient was then transported to a hospital where an MRI of the

cervical spine determined the patient had a large disc herniation at the

C6-C7 level.

•The next day, an anterior cervical discectomy and spinal fusion was

performed. Following surgery, the patient was left with paralysis in his

lower extremities. After an extensive stay in a rehabilitation facility and

subsequent physical therapy the patient has limited feeling in his legs

and is confined to a wheelchair.

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•Through a mutual friend, our insured learned that the patient may have been

less than candid during their consultation. Specifically, the PT learned that

the patient had been experiencing neck and back problems for

approximately three weeks and had apparently been in some sort of

accident. However, despite an exhaustive search, we were unable to confirm

proof of this accident.

•PT expert witnesses for the defense were supportive that the PT met his

standard of care in light of the direct access provisions in this state.

However, two expert neurosurgeons were unsupportive and advised that the

PT’s actions caused the paraplegia. A suit was filed alleging negligent

treatment and failure to take a thorough patient history, ultimately resulting in

paralysis. To compensate for medical bills, pain and suffering and lost

wages, a demand in excess of $5,000,000 was sought.




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negligent?





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• Indemnity payment: $1,000,000


Without expert support, and in consideration of

the patient’s paralysis, this was a claim to

resolve. The matter was ultimately settled prior

to trial.








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•Know and practice within your state-specific scope of practice and

standard of care.

•Elicit the patient’s concerns and reasons for the visit and address

those concerns.

•Gather, document and utilize an appropriate patient clinical history,

as well as relevant social and family history. A new patient clinical history

must be performed at the beginning of each “new problem” visit.


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•Adopt an informed consent process that includes discussion and

teach-back from the patient and demonstrate that the patient

understands the risks associated with treatment.

•Document all interactions with the patient, authorized family

members and professional staff.

•Cease any treatment deemed to present a safety risk to the patient

and contact the supervising physical therapist and/or physician to make

necessary adjustments to the treatment regimen.

•Factually and thoroughly document any unusual occurrences that

arise during the patient’s treatment of care.




INCIDENT REPORTINGPT

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Spotting and reporting incidents

Any error or omission in professional services that has resulted in a

client injury or client complaint, and that you think may lead to a claim,

such as:

•Statement from a client indicating that he/she may be considering filing a

claim

•Concerns such as adverse treatment results

•Letter of complaint

•A heated disagreement

•Repeated failure to keep appointments without adequate explanation

Reportable Incidents – How do you know?



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•Falls

•Treatment-related injuries such as burns

•Complaints of inadequate care

•Complaints of inappropriate touching

•Complaints about unexpected or unusual pain or discomfort

•Equipment-related injuries or events that have the potential for injuries

such as malfunctioning equipment

•Treatment-related injuries such as missed or incorrect diagnosis

Reportable Incidents – Examples

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•Follow your practice’s guidelines for the completion and routing of an

incident report

•Typical process:

–Written, objective report of the facts to be completed by the physical

therapist directly involved

–Submit within 24 hours to a designated member of the management

team

Incident Reports – What to include



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• Objectively describe the circumstances pertaining to the incident.

–Give only the facts.

o “The PT placed the hot pack on the patient/client’s lower back for 15

minutes..”

–Don’t draw conclusions about cause or fault.

o “The PT left the hot pack on too long because she was called away to

another client.”

–Don’t record impressions.

o “The client was not paying attention.”

Incident Reports – What to include

Just record the facts clearly and succinctly.

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Factually note:

What occurred

What the patient/client stated

What steps were taken to resolve or relieve the situation

Whether the patient/client responded favorably to those steps

The patient/client’s condition and mode of leaving following the

appointment

The follow-up or referral instructions provided to the patient/client

Incident Reports – How to complete



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•Incident reports are for internal use only

•The law recognizes this need for confidentiality

•Organizations should have guidelines to protect the confidentiality of

incident reports

•Confidentiality is crucial not just for the report, but also for information that’s

in the report

The Importance of Confidentiality

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•Limit your discussions about the incident to the few designated individuals

who have a need to know

–Practice Manager or Supervisor

–Risk Manager

–HPSO, your insurance company

•Resist the temptation to describe the incident to friends or family.

Confidentiality - Strategies



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•Be aware that a breach of confidentiality may itself become the basis for a

lawsuit.

•Keep any reference to an incident report out of the client’s record!

–Do not copy the report,

–do not place the report in the client’s treatment record,

–Do not refer to the report in your treatment record or client

documentation.

Confidentiality - Strategies

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•Medical records are legal documents

•Can provide evidence against miscommunication and misunderstanding

•May help guard against a lengthy litigation process

•No matter what we do or say we do, it is virtually impossible to prove unless it is

clearly documented

•General rule: "Not documented, not done“

•A well documented record can

– Demonstrate to Regulatory Board that you are a competent Physical Therapist

– Keep you from being named in suit

– Keep you out of court if you ARE named in suit.

– Help you win if you do go to court.

Importance of Good Documentation



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•Contemporaneous

•Objective

•Truthful

•Appropriate

Good Documentation is…

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1. DO chart time, type of treatment given, duration of hands-on treatment,

the position in which the client was situated and a summary of techniques

used.

2. DO chart any assignment of treatment tasks to other personnel, including

staff members involved, introduction to client, and instructions given.

3. DO make sure each client record page has the client’s name and the date

on it.

Documentation - Top 10



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1. DO chart an action at the time you perform it; contemporaneous notes are

the most credible.

2. DO write to reflect an organized process: from current health conditions,

other medications and therapies being used, lifestyle factors including diet

and exercise, prior experience with therapy, to reasons for receiving

therpay now.

3. DO write concise, clear notes reflecting facts.


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6. DO use correct medical terminology whenever possible. Use words that

describe exact anatomy, physiological responses or specific techniques of

bodywork.

7. DO document only your own observations: what you see, hear, and feel.

8. DO chart precautions and preventive measures; such as cautions for

therapy, or specific areas of concern.

9. DO chart any recommendations made to the client, for example,

suggestion for a simple exercise to alleviate back pain.




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•Know and comply with your state scope of practice requirements, physical therapy therapy practice act, and facility policies, procedures and protocols.

•Follow documentation standards established by professional organizations and comply with your employer’s standards.

•Develop, maintain and practice professional written and spoken communication skills.

•Emphasize ongoing client assessment and monitoring.

Protecting Yourself - Key Takeaways

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CLAIM SCENARIOPT

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Case Summary

•The patient, a 49 year old male, was receiving physical therapy from our

insured physical therapist for neck and shoulder pain that had been the

result of a motor vehicle accident 2 months prior.

•During his seventh therapy session, the patient was using a dip machine

which he had used on multiple prior occasions. After completing multiple

repetitions, he told the PT that “something about the machine didn’t feel

right”. The PT could not observe anything visibly wrong so he got on the

machine and did 10 repetitions. He noticed no problems and told the

patient that the machine was fine.

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Case Summary

•The patient completed 5-7 repetitions when the machine malfunctioned.

The bar on which his feet were resting went into freefall and dropped a

couple feet. The patient was able to catch himself by holding on the

handlebars.

•The PT checked on the patient who advised “I’m alright, it just scared

me”. Nevertheless, the PT did an immediate evaluation but could find no

injury to the patient.

•The patient returned to his exercise regime and later returned to work at

his hair salon. The patient returned for eleven therapy sessions and

showed good signs of improvement.



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•At the time of the incident, the PT’s private practice performed daily

cleaning of every machine and maintained weekly inspection logs on all

equipment. Logs were retained for a year and discarded. Although the

dip machine was 15-18 years old, no problems had been previously

reported.

•After the incident, the machine was marked off-limits. A national repair

company completed repairs the following week. Repair personnel

determined that the pin holding the pulley had broken causing the pulley

assembly to “shear off”. No other problems were identified and the

machine went back into service.


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•The patient saw his primary physician two months after this incident and

complained of increased pain that was work related. Thirteen months

after the incident, the patient continued having pain and ultimately

referred to an orthopedic surgeon. An arthrogram was ordered which

indicated a SLAP (superior labral tear from anterior to posterior). An

arthroscopic open repair of the rotator cuff was performed.




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•The patient filed suit demanding $300,000 in damages and alleging the PT

failed to keep equipment in proper functioning order and to “inspect and

discover possible dangerous conditions.” He also alleged the dip machine

was not appropriate given his condition and that the incident caused the tear

of his right rotator cuff.

•During his deposition, the patient made multiple exaggerated claims about

his on-going pain that he attributed solely to the equipment malfunction.

Additionally, he exaggerated statements about the annual income generated

by his hair salon. His income statements were later contradicted by

information obtained from tax records.

•Finally, the patient acknowledged that his doctor had not placed restrictions

on him as a result of this incident. In consideration of facts weighing in favor

of the PT, the case went to trial.


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negligent?







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• Indemnity payment: $0.00







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•A six day trial ensued. Witnesses included our PT, several of the clinic’s

staff who had been on-site and in view of the incident on that day.

Several expert witnesses were called by both sides including the

patient’s primary care and orthopedic physicians. Defense counsel was

able to successfully argue that the patient had chronic shoulder pain

prior to the incident. This was corroborated by medical records obtained

from the patient’s primary physician.

•Additionally, under cross examination, the patient’s orthopedic physician

did not fully support the patient’s version of events. Finally, the patient

made a poor witness on his own behalf by making exaggerated

statements and becoming quite angry and emotional.




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•The jury deliberated for two hours. Among the documents they called to

review during deliberation were the PT’s medical records and the

patient’s feedback form which had been completed on his last visit. The

feedback indicated the patient as being “very satisfied with care

provided at the clinic”. The jury ultimately found in favor of the PT and

the case was closed.


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•Factually and thoroughly document any unusual occurrences that

arise during the patient’s treatment of care. Refrain from documenting

inappropriate subjective opinions, conclusions or derogatory statements

about the patient.

•Complete an incident/occurrence report according you your

organizational policies and procedures.

•Report possible claim and provide your insurance carrier with as

much information as you can, being sure to include contact information

for the risk manager at your organization and the attorney assigned to the

case by your employer.




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•Sequester all equipment and records involved in any patient related

incident according to your organizational policies and procedures.

•Promptly return calls from your defense attorney and the claim

professional assigned by your insurance carrier. Contact your

attorney or claim professional before responding to calls, emails or

requests for documents from any other party.

•Never testify in a deposition without first consulting your insurance

carrier or, if do not carry individual professional liability insurance, your

organization’s risk manager or legal counsel.


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Sample Incident Report

Sample Incident Report

can be found at

www.hpso.com



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Questions?

Thank You!

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