Insights from the new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) show that the majority of claims against nurse practitioners developed from a failure involving core competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs occurred most frequently.
What the report also found was that in many claims, the nurse practitioner met the standard of care, but the patient was nonetheless dissatisfied, often due to a lack of communication or understanding. The informed consent discussion represents the first step in managing patient expectations, thus reducing the possibility of a misunderstanding and mitigating the risk of a consequent lawsuit.
Additionally, documenting the informed consent process provides the best defense in the event a patient alleges that the proposed treatment, other options, or the potential for injury were not adequately explained to them. Refer to state statutes for guidance on the informed consent process, as there is considerable variance among states. This is especially true when it comes to caring for minors or cognitively impaired patients, and emergency situations.
The informed consent process involves two main components:
- Discussion, providing the patient with sufficient information about and time to consider:
- The nature of the proposed treatment, including rationale, anticipated benefits and prognosis.
- Alternatives to the proposed treatment, including specialty referral options or no treatment at all. This should also include an explanation of why, according to one’s professional judgment, the recommended treatment is preferable to alternatives.
- Foreseeable risks, including potential complications of the proposed treatment and risks of refusing it.
- Documentation of the discussion and the outcome of the discussion in the healthcare information record, which often includes the use of a written informed consent form in addition to the verbal component.
The informed refusal process is similar to, but goes beyond, the process for informed consent. Refusal of care increases the potential liability exposure for the nurse practitioner, but nurse practitioners can help minimize their liability exposure by being aware of their consequent responsibilities and documenting the informed refusal process.
Nurse practitioners who continue caring for a patient after they decline treatment recommendations must be aware of their responsibility to:
- Continue to examine and diagnose the patient for the duration of the practitioner-patient relationship and as long as the patient continues to refuse treatment.
- Continue to inform the patient about the condition and its associated risks, while the practitioner-patient relationship is in place, the condition exists, and the patient continues to refuse treatment.
- Continue to inform the patient how their refusal of treatment may affect treatment of other conditions or problems, when discussing these conditions.
After discussing the potential consequences of refusal with the patient, nurse practitioners should complete a comprehensive progress note and document the refusal using a written form, which should be incorporated into the patient health care information record. Progress notes should document:
- The individuals present during the discussion.
- The treatment discussed.
- The risks of not following treatment recommendations, listing the specific risks mentioned.
- The brochures and other educational resources provided.
- The questions asked and answers given by both parties.
- The patient’s refusal of the recommended care.
- The patient’s reasons for refusal.
- The fact that the patient continues to refuse the recommended treatment.
As the data proves, it is imperative for nurse practitioners to protect their patients and their practice by documenting all phases of medical treatment, discussing (and documenting) the nature of all proposed treatments with patients as well as educating them about the need for follow-up, and signs and symptoms that should prompt a follow-up call.
In addition, today’s nurse practitioners must continuously evaluate and enhance their patient safety and risk management practices by remaining current regarding their clinical practice, medications, biologics, and equipment utilized for the diagnosis and treatment of acute and chronic illnesses and conditions related to one’s specialty and obtain regular continuing education.
Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.
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- Informed Consent and Informed Refusal in Managing Patient Expectations - March 15, 2018
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