HA4050D – Healthcare Law

Discussion 08.2: Missing Records


You are selected to sit on the jury in a medical negligence case. The plaintiff is an infant who was

allegedly injured due to the negligence of hospital physicians and staff when he was born. During

discovery in the case, the patient and his attorney learned that the hospital had “lost” the patient’s

medical records for a critical 18-hour period in which the injury occurred. There was thus no

documentation of how the plaintiff was treated, which staff treated him, or what might have gone


(Note: If you would like to see the real case this scenario is based upon, check out Keene v. Brigham &

Women’s Hosp., Inc., 786 N.E.2d 824 (Mass. 2003). Be warned—the scenario has altered the facts from

the original case. Do not rely upon the real case opinion in formulating your answer to the fictional

scenario in the discussion question.)

1. As a member of the jury, would it surprise you that a hospital could lose a critical record like

this? What is the duty of the hospital to properly maintain the record?

2. As a juror trying to decide the facts of this case, how does it make you feel about the hospital

that this critical record which was vital to the plaintiff’s case was “lost?” How would it affect the

way you would judge the credibility of the hospital’s witnesses and other evidence?

3. What would you expect the judge might do in this situation to punish the defendant hospital? 

Legal Aspects of Healthcare Administration 13th Pozgar 2019 Jones & Bartlett-Vitalsource [email protected]#magicMAN61

Chapter 13

Information Management &

Patient Records

Learning Objectives

Describe the contents of medical records.

Explain the importance of maintaining complete and accurate records.

Explain the ownership of and who can access a patient’s medical record.

Describe the advantages and disadvantages of electronic medical records.

Learning Objectives, cont’d

Describe why the medical record is important in legal proceedings.

Describe a variety of ways in which medical records have been falsified.

Explain what is meant by the medical record battleground.

Information Management

Determine Customer Needs

Set Goals & Establish Priorities

Improve accuracy of data collection

Provide Uniformity in Data Collection Definitions

Limit Duplication of Entries

Information Management, cont’d

Deliver Timely & Accurate Information

Provide Easy Access to Information

Maintain Security & Confidentiality of Information

Enhance Patient Care Activities

Improve Collaboration through Information Sharing

Information Management, cont’d

Establish Disaster Plans for Information Recovery

Provide Orientation & Staff Training

Annual Review of Information Management Plan





Medical Record
Means of Communication

Documentation of Patient’s





Medical Record
Means of Communication, cont’d

Communication Tool (e.g., progress notes)

Protect Legal Interests of Patient & Provider

Provide Database for Use in Statistical Reporting

Continuing Education


Provide Information for Billing

Medical Record Contents

Admission record



Reason for admission

Social security number

Marital status


Health insurance

Medical Record Contents, cont’d

Consent Authorization for Treatment

Advance Directives

History & Physical Exam


Information that Supports the Diagnosis

Patient Screenings & Assessments

Medical Record Contents, cont’d

Treatment plan


Progress Notes

Nursing Notes

* Integrated record includes physician progress & nursing notes along with the notes of other disciplines

Medical Record Contents, cont’d

Strategic Analysis for Healthcare

Chapter 18

Copyright © 2016 Foundation of the American College of Healthcare Executives. Not for sale.

Health Administration Press


Internal Factor Evaluation

Just as an external factor evaluation (EFE) organizes and evaluates the OT section of SWOT, an internal factor evaluation (IFE) addresses the SW section—the internal strengths and weaknesses.

The IFE produces a numeric score that reflects the gravity of each issue listed.

The score will correspond to certain standard strategies that will be discussed in Chapter 19.

Copyright © 2016 Foundation of the American College of Healthcare Executives. Not for sale.

Health Administration Press

Health Administration Press

Internal Factor Evaluation

As you did with the EFE analysis, note that not every item you identified in the SW section of your SWOT analysis is of equal strength or equal weakness.

Some distinction needs to be made between the “great” strengths and weaknesses and the “could be” strengths and weaknesses.

To begin to make these distinctions, review the SW section of SWOT from the previous chapter.

Copyright © 2016 Foundation of the American College of Healthcare Executives. Not for sale.

Health Administration Press

Health Administration Press

Internal Factor Evaluation

The strategist evaluates each strength and weakness and applies a weighting system.

The total when all of the weights have been applied and added is exactly 1.00.

Each individual factor, therefore, receives some portion of 1.00.

The size of that portion reflects the strategist’s subjective evaluation of how important each internal factor is to successful competition within the firm’s industry.

The more important the factor, the higher is the weight assigned.

The total of 1.00 is the sum of the whole column, including both strengths and weaknesses.

Copyright © 2016 Foundation of the American College of Healthcare Executives. Not for sale.

Health Administration Press

Health Administration Press

Internal Factor Evaluation

Copyright © 2016 Foundation of the American College of Healthcare Executives. Not for sale.

Health Administration Press

Health Administration Press

Internal Factor Evaluation

The previous slide shows, for instance, that the weakness associated with managing a significant population without health coverage is deemed to be more significant than the strength of the organization’s technology, administration, or facilities.

Note that there is no one “correct” weight for any factor.

The accuracy of the analysis depends on the strat

Chapter 18

Legal Reporting Requirements

Learning Objectives

Describe various forms of child abuse, how to recognize it, and reporting requirements.

Describe various forms of elder abuse, how to recognize it, and reporting requirements.

Explain why it is important to report communicable diseases, adverse drug reactions, & infectious diseases.

Learning Objectives (cont’d)

Discuss the importance of reporting births and deaths.

Explain how & why physician incompetency is reported.

Understand the importance of incident reporting, sentinel events, & the purpose of root cause analyses.


Abuse in the healthcare setting often occurs to those who are most vulnerable and dependent on others for care.

Abuse can take many forms, such as physical, psychological, medical, and financial.

Abuse is not always easy to identify because injuries can often be attributed to other causes.

Child Abuse

Intentional serious mental, emotional, sexual, &/or physical injury inflicted by family or other person responsible for care.

Child Abuse Prevention & Treatment Act (CAPTA)

Minimum standards states must incorporate in their statutory definitions of child abuse and neglect.

Child Abuse
Who Should Report

Healthcare setting

Administrators, physicians, interns, registered nurses, chiropractors, social service workers, psychologists, dentists, osteopaths, optometrists, podiatrists, mental health professionals, & volunteers in residential facilities

Penalties for failure to report

States vary on penalties

Child Abuse
How to Detect

Indicators of abuse and maltreatment that appear to be part of a pattern

Physical indicators




Cigarette burns

Child Abuse
How to Detect (cont’d)

Behavioral indicators

Diminished psychological or intellectual functioning

Failure to thrive

No control of aggression

Self-destructive impulses

Decreased ability to think and reason

Acting out and misbehavior, or habitual truancy

Child Abuse (cont’d)

Good faith reporting

Psychologist Immune to Liability

Failure to report child abuse

Psychologist’s Failure to Report Abuse

Nurse’s Failure to Document and Report

Physician Entitled to Immunity

Child Abuse Can Be Elusive

Senior Abuse

Mistreatment: Results in Harm or Loss

It can involve

Physical & Sexual Abuse

Domestic & Ps