Case Study: Questionable Medical History
Read the case study below then prepare a 10 slide powerpoint.
Questionable Medical History from Ch 10.
Smith was admitted to Community Hospital for surgery. Community Hospital medical staff bylaws require that a history and physical (H&P) exam be completed prior to patients undergoing surgery. Smith’s attending physician did not complete the H&P form. He simply drew a diagonal line from the top right to the bottom left of the H&P, indicating that the patient had no history of or current disease processes.The patient’s nurse, per hospital policy, completed a nursing assessment. The nurse documented on the patient admission assessment form that the patient had a history of transient ischemic attacks, diabetes, and hypothyroidism.The anesthesiologist did not perform an anesthesia assessment before surgery. General anesthesia was administered without knowing the patient’s previous experiences, if any, with anesthesia.Failure of the attending physician to complete an appropriate H&P examination and the anesthesiologist’s failure to perform a pre-anesthesia assessment placed the patient’s life and health at risk. The physician did not complete the H&P. He merely went through the motions of completing an H&P examination because it was mandated that the patient have an H&P in his medical record prior to surgery.
Once you have read the “Questionable Medical History Conducted Case Study,” located in Chapter 10 of the textbook. You are a health care administrator and have come across a case study from a community hospital. In order to prevent this incident from occurring in your practice setting, prepare a 10-12 slide PowerPoint educational presentation for your staff. Include the following in your presentation:
Describe the ethical issues and principles that were violated in this case.
Describe the potential legal issues of concern.
What tools or resources should this organization pursue in order to ensure high quality history and physical (H&P)?
Explain whether negligence has occurred in this case.
Explain which requirements meet the criteria for determining negligence in court.
Describe how this situation can be prevented in your practice setting.
Use speaker notes to expound and add detail.
