VISTA's notification system is one of the benefits to the physician that is frequently touted by the VA. It truly is advantageous to both the physician and the veteran when it is properly used. Each day when the physician logs onto the CPRS system they're provided with a variety of administrative reminders of things that they need to do, unsigned reports, is one of them. The system is supposed to provide the VA's administration with the ability to oversee incomplete records, and at some point the administration is supposed to deal with the doctor over this. These view alerts and whether they are done or undone are kept, or not kept, or defined by the individual hospitals business rules that they use for VISTA CPRS. Unfortunately, when the VA's doctors do not look at the records, or choose to no not sign a record for a prolonged period of time, the VA chooses to make sure that VISTA CPRS does not memorialize this phenomenon. I was told at one deposition that after 60 days the reports of unsigned reports are deleted by the system, to save space Why the administrative staff loses interest in reports that are unsigned for more than 60 days remains a mystery to me. Eventually, after several months, the attending surgeon electronically signed the first discharge report indicating that the hardware was in normal placement. This was well after the veteran had his surgery to remove and reposition the hardware. The attending did not include any information as to why she was signing the resident's note, there was not even the briefest of mention that the CT scan had in fact shown a different result than the discharge report, or the operation removing and replacing the screws months earlier. Since this document was not electronically signed, the attending could have easily changed the note to include the additional information that would have more accurately reflected what had happened. If it had been already electronically signed by the resident, she would've had to make an addendum to it. In the days of a paper record, if something was changed, it would have to be crossed out, erased, whited out, or smudged in a manner that gave you a fighting chance to realize that something wasn't right. Today you must be much more alert to see if something has been changed.. The records that you receive are merely a report based on what VISTA CPRS has been programmed to spit out in response to the request that is made of it. The report is pulled from various data fields. Some data fields are used in more than one report, other data fields are unique to specific reports. Some reports, and entries in the medical record, when they are either compiled, to be displayed on a screen at the VA Hospital, or in the clinic records that you receive or a combination of data pulled from various places within the clients electronic data. To go back to my prior example of Time Matters, one of the features of practice management software is that it allows data to be entered in one field and the data from that field is used by various templates to supply the information for different forms. Entering the client's name and address in one location in Time Matters, results in Time Matters using that information every time something requires the client's address, whether it's a letter of a pleading. When you change the client's address, the client's old address does not appear next to the new one, in the next letter all you will see is the new address. The VA system operates in a similar manner. Some records are designed to show only the information that was present at a specific time period. You may never know what was contained in that field at the time that your client received medical care, if the data that populate that field ever changes. This makes finding changes in the medical record difficult to find. For example, I recently handled a case for a veteran who was scheduled for a routine laparoscopic chlostectomy. The procedure was converted to an open procedure, due to problems that were encountered after the trocar was inserted. What had been scheduled for 2 and 1/2 hours as a same day procedure, took 7 hours, and resulted in the veteran spending weeks in the hospital, instead of going home that day to her family as planned. When the operation was over, the surgeon, a well qualified attending came out and told the veteran's husband that when she was opened up, it was more complex than had been anticipated and that he was rushed in to complete the operation. The operation report, as well as the nurse before operative report both listed the attending physician as the surgeon as doing the entire procedure. The resident was listed as the first assistant surgeon on the copies of these records that my clients received after she was discharged. Neither report made any notation of the attending being called to the operating room, after things did not go well for the resident. All of the written documentation made it seem like the attending was there the whole time. The government claimed that the attending was there the whole time, the veteran's spouse could not be correct. When this veteran had originally gone to the ER at the VA, she was correctly diagnosed as having gallstones, within 24 hours of her presentation. The physician ordered that ordered the surgical consult, requested the veteran be seen within one week. Unfortunately, it took the surgical clinic more than a month to schedule the appointment for her to be seen by a surgeon. She was eventually overbooked into an appointment another two weeks that took place six weeks after the ER had requested it. Surgery was originally scheduled for another seven weeks after the consult actually took place. When the operation was originally scheduled, it was listed with one surgeon. Three weeks before the surgery was originally scheduled for, the VA contacted the veteran and said that we have a cancellation in two days and we are going to move you into it. This resulted in the veteran being assigned to a resident in the surgery scheduling field, which is also what populates the surgeon field on the nurse inter operative report, as well as the nurse interoperative report. The nurse interoperative note is supposed to be the record of what happens during the procedure. This report tracts a variety of items including when nursing personnel arrived and be the operating room, as well as the presence of all individuals in the operating room. It notes times for the start and ending of many portions of the operation and it will it is started by the nurse at the beginning of the procedure and completed at the end of the procedure. Understandably this note is open for several hours while the veteran is being operated on. Like many of the VA's records it is free text and editable until it is digitally signed; therefore, any changes or corrections are not visible. When we received the scheduling document, printed with the request that he showed a history of deletions, it became apparent that one surgeon's name had been displayed in this field for several weeks. Two days before the operation, it was changed to another surgeon's name, this time the resident. The resident's name ROwas apparently displayed in this field the day before the operation, the resident's name was there when the plaintiff arrived at the hospital several hours before the operation began, the resident's name was there when the plaintiff was placed under anesthetic, and when the operation began. Ten minutes after the procedure had been converted, the name of the surgeon changed from the resident RO to the attending surgeon MA. He admits he was at a casino drinking when he was called into work. Thank you for your kind comments. Proof that this mistake AND NOTHING ELSE caused the injuries you suffered; and Early adoption of a new medical device by a physician carries with it some degree of malpractice liability risk. The legal standard for malpractice varies from place to place, but generally requires an evaluation of the physician's conduct either against that of a hypothetical reasonable physician, or else against professional custom. Where the use of a new device involves a significant departure from traditional modalities of care, and a bad clinical result follows, questions may arise about whether the legal standard for malpractice has been violated. We suggest that a liberal interpretation of the malpractice standard of care is appropriate, and even necessary to avoid the potential for perverse disincentives to technical innovation in medicine. PMID:19715141 Law Solicitor Alma Michigan 48802. 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