If a patient care problem occurs, for any
reason, your best approach is to pursue the best care for it,
and document that effort well. With regard to malpractice, two
issues that affect the outcome most powerfully. First your concern
for the patient, which will be perceived from your patient care
and testimony if it should go to that. Secondly, any impression,
real or argued by a plantiff's attorney, that there was an effort
to cover up or alter records.
Your best course is to work to minimize or correct the clinical
problem. And extablish that your efforts are within the standard
of care, in the chart. Obtain consults to deliver the best care
with documentation of the effort, and documentation that the standard
of care for the problem is being applied.
Do not let anyone alter or remove notes. The problem will go from
manageable to unforgivable with such actions.
Beyond the clinical care, consider that
if it should lead to malpractice, your challenge with regard to
a trial is establishing that you are within the standard of practice.
The other issue will be what the consequences are for the patient,
and only your effort to deliver the best care can help. But the
standard of care argument will involve two experts arguing opposite
sides. If you can establish in the chart additional expert opinion
that the resolution of the problem was within the standard of
care, and perhaps that the clincal problem occurred as an event
within the standard of care, it will help. In doing so some additional
opinions are on acting on your behalf at the time of the problem.
This helps years later in a courtroom when memory will not be
as effective as ink on paper, to follow the chinese proverb.