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Chapter 10 Medical Staff Organization and Malpractice Patient Assessments
▸ PATIENT ASSESSMENTS Patient assessments involve the systematic collection and analysis of patient-specific
data that are necessary to determine a patient’s care and treatment plan. A patient’s
plan of care is dependent on the quality of those assessments conducted by the
practitioners of the various disciplines (e.g., physicians, nurse practitioners,
dietitians, physical therapists).
The physician’s assessment must be conducted for elective admissions within 24
hours of a patient’s admission to the hospital. Emergency patients are, out of
necessity, evaluated and treated promptly on arrival to the hospital’s emergency
department. The findings of the clinical examination are of vital importance in
determining the patient’s plan of care. The assessment is the process by which a
doctor investigates the patient’s state of health, looking for signs of trauma and
disease. It sets the stage for accurately diagnosing the patient’s medical problems. A
cursory and negligent assessment can lead to a misdiagnosis of the patient’s health
problems and/or care needs and, consequently, to poor care.
Failure to conduct a thorough patient assessment and reassessment can result in
disciplinary action against a physician, as noted in the following case.
PHYSICIAN FAILS TO CONDUCT A COMPLETE ASSESSMENT
Citation: Moheet v. State Bd. of Regis. for Healing Arts, 154 S.W.3d 393 (Mo. Ct. App. 2005).
Facts J.D., a 40-year-old male suffering from high blood pressure, felt a sudden and severe headache while driving. Soon after he returned home, he asked his son Jason to call an ambulance. When the paramedics arrived, they took J.D.’s history, which included
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hypertension (high blood pressure), and a list of J.D.’s medications, one of which was to treat the hypertension.
The nurse manager of the emergency department, Bouldin, RN, was waiting to perform triage on J.D. when he arrived. Bouldin filled in an Emergency Room Record form (the “E.R. form”) with J.D.’s vital signs. J.D.’s blood pressure was 170/130 at 4:50 PM. J.D.’s wife gave Nurse Brooks J.D.’s medical history, which in addition to high blood pressure, included depression, alcoholism, and left arm numbness.
Dr. Moheet was on duty in the emergency room that day. At 5:05 PM, Dr. Moheet began examining and taking a history from J.D. He observed that J.D. was lying on a backboard in a cervical collar, holding onto the side rails of the gurney, clenching his teeth, and going into spasms. When asked why he was in the emergency room, J.D. responded that he was having neck pain that radiated into the back part of his head. Dr. Moheet asked J.D. if he had hurt himself, and he said that he fell while sledding in the snow (referring to an incident the previous day when sledding with his children). He complained of numbness in the left arm. Dr. Moheet was hampered in taking J.D.’s medical history because J.D. was unhappy with the questions and repeatedly requested pain medication.
Dr. Moheet checked J.D.’s breathing, pulse, lung sounds, and abdomen. He then did a neurologic check, which included checking his ability to feel sensations. J.D. had decreased sensation in the thumb, outer forearm, middle finger, and on the inner side of the left hand. To Dr. Moheet, these sensory changes suggested radiculopathy (nerve impingement due to a cervical disk problem). J.D. was given an injection for pain. Dr. Moheet sent J.D. for X-rays. Although J.D. had informed the nurse of a sudden onset of head pain, Dr. Moheet did not order a computed tomography (CT) scan of the head. J.D.’s reflexes were normal. When it was determined that J.D. did not have a neck fracture, the collar, cushion, and backboard were removed, and he was returned to the emergency room.
At 6:40 PM, Dr. Moheet again examined J.D. and checked his neurologic responses. At this time, J.D. was sitting upright on the gurney, and he told Dr. Moheet that he was feeling 50% better. Dr. Moheet told J.D. of his diagnosis of a C-6 radiculopathy (pinched sixth nerve) on the left side. He told J.D. that the X-ray was negative and that he was being discharged with a muscle relaxant and an anti-inflammatory
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painkiller. J.D.’s wife asked whether those medications would cause a problem with J.D.’s blood pressure. Dr. Moheet said they would not. Dr. Moheet did not consider this mention of blood pressure to be a reason to further examine the patient. J.D. was given a soft collar for his neck and was released to go home.
Dr. Moheet later charted his findings for J.D. based on his notes. Dr. Moheet did not know J.D.’s blood pressure when he treated him and did not review the ambulance records or the E.R. form. Dr. Moheet expected his nurses to inform him of any abnormalities in the patient’s vital signs. J.D. did not inform Dr. Moheet that he had high blood pressure nor did he mention that he had stopped taking his medication.
At approximately 6:30 the next morning, J.D.’s wife found J.D. unconscious on the bedroom floor and could not revive him. An ambulance crew responded and took J.D.’s blood pressure four times between 7:16 and 7:50 AM. The readings were extremely high: 220/120; 200/128; 210/118; and 228/108. The ambulance crew gave J.D. a drug for hypertension and took him to the hospital.
At the hospital, a CT scan was taken, and emergency room personnel informed Dr. Boland, a neurosurgeon, that J.D. had an abnormal CT scan, was comatose, and needed emergency neurosurgical treatment. Dr. Boland diagnosed a spontaneous intraventricular hemorrhage in the fourth ventricle of his brain (a hemorrhagic stroke). The blood from the hemorrhage had clotted and blocked the flow of spinal fluid. The excess fluid in his brain built up tremendous pressure, causing J.D. to lapse into a coma. Dr. Boland believed that J.D. had already suffered the hemorrhage and had stopped bleeding by the time he arrived at the emergency room the first time and was seen by Nurse Bouldin and Dr. Moheet.
Dr. Boland told J.D.’s wife that J.D. needed an emergency procedure to avoid imminent death. His wife authorized the procedure. The procedure was performed in the emergency department due to the urgency. J.D. spent a week in neuro-intensive care, a week in a step-down area, and a week on a rehabilitation floor. At the time of the hearing, J.D. was deceased; but neither party has discussed whether the cause of death was related to the stroke.
The State Board of Registration for the Healing Arts Administrative Hearing Commission found cause to discipline Dr. Moheet’s medical license by subjecting it to a public reprimand.
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The pertinent parts of the Board’s complaint alleged the following:
While J.D. was in the emergency room the day before the admission, licensee knew or should have known that J.D.’s blood pressure was very high. Failure to ascertain a patient’s vital signs, including blood pressure, in the practice of emergency medicine is below the standard of care. Licensee’s failure to assess J.D.’s blood pressure in the emergency room constitutes gross negligence. Because of licensee’s failure to assess J.D.’s blood pressure in the emergency room, J.D. was deprived of timely diagnosis and treatment of the bleed, reducing the likelihood of a favorable clinical outcome. While J.D. was in the emergency room the day before the admission, licensee failed to do a complete physical examination of the patient. While J.D. was in the emergency room the day before the admission, licensee failed to obtain appropriate laboratory tests. Licensee’s failure to adequately assess, diagnose and treat J.D. when he presented in the emergency room was below the standard of care for an emergency department physician. Licensee’s conduct, as set forth herein, constitutes incompetency and gross negligence in the practice of medicine. Dr. Moheet appealed the decision of the Administrative Hearing Commission.
Issue Did the Administrative Hearing Commission have cause to discipline Dr. Moheet’s medical license by subjecting it to a public reprimand.
Holding The Missouri Court of Appeals affirmed the Administrative Hearing Commission’s decision.
Reason Dr. Moheet had adequate notice of the charges against him in that he was fully aware of the link between his failure to obtain an adequate medical history and the possibility of harm to the patient. He had sufficient notice of the allegation of his
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To ensure a comprehensive process for assessing patient care needs, the
organization should conduct a self-check that includes written policies and
procedures that describe the requirements for screenings and assessments by
profession. For example, criteria for nutritional screens and assessments should be
developed and approved by the medical staff. Patients on special diets should be
monitored to ensure that they receive the appropriate food tray. Functional screens
should be developed and implemented that include a patient’s neurologic and
functional status (e.g., range of motion, strength).
Unsatisfactory History and Physical Failure to obtain an adequate family history and perform an adequate physical
examination violates a standard of care owed to the patient. In Foley v. Bishop Clarkson Memorial Hospital, the spouse sued the hospital for the death of his
wife. During her pregnancy, the patient was under the care of a private physician.
She gave birth in the hospital on August 20, 1964, and died the following day. During
July and August, her physician treated her for a sore throat. There was no evidence
in the hospital record that the patient had complained about a sore throat while in
the hospital. The hospital rules required a history and physical examination to be
written promptly (within 24 hours of admission). No history had been taken,
although the patient had been examined several times in regard to the progress of
her labor. The trial judge directed a verdict in favor of the hospital.
On appeal, the appellate court held that the case should have been submitted to the
jury for determination. A jury might reasonably have inferred that if the patient’s
condition had been treated properly, the strep throat infection could have been
combated successfully and her life saved. It also reasonably might have been
inferred that if a history had been taken promptly when she was admitted to the
hospital, the sore throat would have been discovered and hospital personnel would
have been alerted to watch for possible complications of the nature that later
failure to obtain an adequate patient history, and his own pleading showed that he knew the charges he would be defending against.
The testimony of the expert witnesses, combined with the other evidence in the record, constituted competent and substantial evidence to support the commission’s finding of conduct that might be harmful to a patient. There is ample evidence in the record to support a finding of gross negligence.
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developed. Quite possibly, this attention also would have helped in diagnosing the
patient’s condition, especially if it had been apparent that she had been exposed to
a strep throat infection. The court held that a hospital must guard not only against
known physical and mental conditions of patients, but also against conditions that
reasonable care should have uncovered.
In another case, the physician in Moheet v. State Board of Registration for the Healing Arts had adequate notice of the charges against him, in that he was fully
aware of the link between his failure to obtain an adequate medical history and the
possibility of harm to the patient. He had sufficient notice of the allegation of his
failure to obtain an adequate patient history, and his own pleading showed that he
knew the charges he would be defending against. The testimony of the expert
witnesses, combined with the other evidence in the record, constituted competent
and substantial evidence to support the commission’s finding of conduct that might
be harmful to a patient. There is ample evidence in the record to support a finding
of gross negligence.
There was substantial evidence in Solomon v. Connecticut Medical Examining Board to support disciplinary action against a physician where the record
indicated that the physician failed to adequately document patient histories,
perform thorough physical examinations, adequately assess the patient’s condition
order appropriate laboratory tests, or secure appropriate consultations. The
Connecticut Medical Examining Board found that the physician had administered
contraindicated medications to patients and did not practice medicine with
reasonable skill and safety and that his practice of medicine posed a threat to the
health and safety of any person. The board concluded that there was a basis on
which to subject the physician’s license to disciplinary action.
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