Treating Infectious Diseases – Accurate Documentation Vital

Medical transcription of doctors’ recorded observations and treatment details is of great significance from the point of view of appropriate diagnosis and treatment. The transcripts have to be accurate, and there is no room at all for error. Physicians cannot afford to order medically unnecessary procedures, diagnostics and hospitalization with a view to mitigate risk and second-guessing, because this is very likely to invite penalty for malpractice and wastefulness.

In the present scenario where more cases of infectious diseases are being reported today in the US than in previous years, accurate documentation has become all the more vital. Infectious diseases are a grave threat to patients as well as those who come in contact with them. In addition, they also pose new malpractice risks.

Rise in Infectious Diseases Increase Stress on Staff

The CDC reports that the first half of this year saw more than 288 measles cases being reported, which is alarming considering the fact that measles was eradicated in 2000. And now, Ebola has made its way to the country too. With these infectious diseases, any negligence or mismanagement in hospitals could end up with serious malpractice consequences for patients and staff as the flawed diagnosis of Thomas Eric Duncan, the first Ebola victim in the United States, proved. Malpractice could invite legal action and bring with it a host of issues that could tarnish the reputation of the healthcare practice.

The risk of malpractice is greater when a healthcare team, consisting of a physician who leads nurses and physician assistants, handles treatment. A mistake by any of them will affect the physician leader of the team who will be held responsible for the actions of others as part of “vicarious liability.” The responsibility is assigned to the professional with a legal relationship to the damage causing member of the team.

Preventing Malpractice

  • Efficient and consistent communication between various members of the care team is essential, right from the front-office staff to the physician. The late diagnosis of Thomas Duncan was the result of failure of communication between the nursing staff and the physician at the Dallas hospital.
  • Consistent patient flow protocols are vital to minimize the risk of oversight. The procedures must also be reviewed from time to time and the staff made fully aware of the changes.
  • To prevent malpractice, the discussions about such infectious diseases must be documented as should discussions on serologic evaluations.
  • Hospitals must allow only staff members having immunity to work with infectious disease patients. Immunization tracking and accurate documentation must be made up to date.
  • The staff should also be trained in isolation techniques and using protective equipment. Individuals exposed to the disease should be notified.

Ensuring Accurate Medical Transcription of Physicians’ Notes and Interactions

Any reports relevant to treating patients must be transcribed and the transcripts maintained scrupulously. Discussions between the members of the care team, diagnoses made, tests ordered, treatments administered – every detail should be clearly recorded to avoid ambiguity at a later stage. Apart from reducing the risk for malpractice, efficient and reliable documentation will also facilitate providing the right treatment for the patient and improve patient outcomes.