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Disaster Documentation for the Clinician

Published online by Cambridge University Press:  25 July 2013

Richard M. Zoraster  and
Christopher M. Burkle
Richard M. Zoraster*
Affiliation:
Los Angeles County Emergency Medical Services Agency, Los Angeles, California and University of Hawai'i Office of Public Health Studies, John A. Burns School of Medicine, USA
Christopher M. Burkle
Affiliation:
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
*
Address correspondence and reprint requests to Richard M. Zoraster, MD, MPH, Los Angeles County Emergency Medical Services Agency, 1011 Pioneer Blvd, Ste 200, Santa Fe Springs, CA 90670 (e-mail [email protected]).
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Abstract

Documentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?

In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)

Keywords

DisasterDocumentationMedical recordLiabilityInformed consent
Type
Special Focus
Information
Disaster Medicine and Public Health Preparedness , Volume 7 , Issue 4 , August 2013 , pp. 354 - 360
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. This is a work of the U.S. Government and is not subject to copyright protection in the United States. 2013 

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References

1.Hripcsak, G, Vawdrey, DK, Fred, MR, Bostwick, SB. Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc. 2011;18:112-117.CrossRefGoogle ScholarPubMed
2.O'Leary, KJ, Liebovitz, DM, Baker, DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1:88-93.CrossRefGoogle ScholarPubMed
3.Oxentenko, AS, West, CP, Popkave, C, Wineberger, SE, Kolars, JC. Time spent on clinical documentation: a survey of internal medicine residents and program directors. Arch Intern Med. 2010;170:377-380.CrossRefGoogle ScholarPubMed
4.Hanfling, D, Altevogt, BM, Gostin, LO. A framework for catastrophic disaster response. JAMA. 2012;308:675-676.CrossRefGoogle ScholarPubMed
5.White, DB, Katz, MH, Luce, JM, Lo, B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132-138.CrossRefGoogle ScholarPubMed
6.Moskop, JC, Iserson, KV. Triage in medicine. part II: underlying values and principles. Ann Emerg Med. 2007;49:282-287.CrossRefGoogle Scholar
7.Annas, GJ. Standard of care--in sickness and in health and in emergencies. N Engl J Med. 2010;362:2126-2131.CrossRefGoogle ScholarPubMed
8.Schultz, CH, Annas, GJ. Altering the standard of care in disasters--unnecessary and dangerous. Ann Emerg Med. 2012;59:191-195.CrossRefGoogle ScholarPubMed
9. Handicap International. Preliminary findings about persons with injuries. Haiti earthquake 12 January 2010. Handicap International website; January 29, 2010.Google Scholar
10.Van Hoving, DJ, Wallis, LA, Docrat, F, De Vries, S. Haiti disaster tourism--a medical shame. Prehosp Disaster Med. 2010;25:201-202.CrossRefGoogle ScholarPubMed
11.Knowlton, LM, Gosney, JE, Chackungal, S, etal. Consensus statements regarding the multidisciplinary care of limb amputation patients in disasters or humanitarian emergencies: report of the 2011 Humanitarian Action Summit Surgical Working Group on amputations following disasters or conflict. Prehosp Disaster Med. 2011;26:438-448.CrossRefGoogle ScholarPubMed
12.Chu, K, Stokes, C, Trelles, M, Ford, N. Improving effective surgical delivery in humanitarian disasters: lessons from Haiti. PLoS Med. 2011;8:e1001025.CrossRefGoogle ScholarPubMed
13.Sonshine, DB, Caldwell, A, Gosselin, RA, Born, CT, Coughlin, RR. Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care. Clin Orthop Relat Res. 2012;470:2895-2904.CrossRefGoogle ScholarPubMed
14. Fink S. The deadly choices at memorial. The New York Times; August 25, 2009. http://www.nytimes.com/2009/08/30/magazine/30doctors.html?_r=4. Accessed September 24, 2012.Google Scholar
15.Okie, S. Dr. Pou and the hurricane--implications for patient care during disasters. N Engl J Med. 2008;358:1-5.CrossRefGoogle ScholarPubMed
16.Chackungal, S, Nickerson, JW, Knowlton, LM, etal. Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space. Prehosp Disaster Med. 2011;26:429-437.CrossRefGoogle Scholar
17.Brett, AS. New guidelines for coding physicians’ services--a step backward. N Engl J Med. 1998;339:1705-1708.CrossRefGoogle ScholarPubMed
18.Hand, RW. E&M guidelines: is the medical record a database repository or a communication tool? Chest. 1998;113:1432-1434.CrossRefGoogle ScholarPubMed
19.Dawson, B, Carter, K, Brewer, K, Lawson, L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11:116-119.Google Scholar
20. Medicare and Medicaid programs; hospital conditions of participation: requirements for history and physical examinations; authentication of verbal orders; securing medications; and postanesthesia evaluations. Final rule. Fed Regist. 2006;71:68671-68695.Google Scholar
21.Devereaux, AV, Dichter, JR, Christian, MD, etal. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(suppl 5):51S-66S.CrossRefGoogle ScholarPubMed
22.Christian, MD, Toltzis, P, Kanter, RK, etal. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12:S109-S119.CrossRefGoogle ScholarPubMed
23.Hick, JL, Hanfling, D, Cantrill, SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59:177-187.CrossRefGoogle ScholarPubMed
24.Hanfling, D, Altevogt, BM, Viswanathan, K, etal. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: National Academies Press; 2012.Google Scholar
25.Goldstein, NE, Cohen, LM, Arnold, RM, Goy, E, Arons, S, Ganzini, L. Prevalence of formal accusations of murder and euthanasia against physicians. J Palliat Med. 2012;15:334-339.CrossRefGoogle ScholarPubMed
26.Hodge, JG, Garcioa, AM, Amderspm, ED, Kaufman, T. Emergency legal preparedness for hospitals and health care personnel. Disaster Med Public Health Prep. 2009;3(suppl 1):S37-S44.CrossRefGoogle ScholarPubMed
27.Caro, JJ, DeRenzo, EG, Coleman, CN, Weinstock, DM, Knebel, AR. Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making. Disaster Med Public Health Prep. 2011;5(suppl 1):S46-S53.CrossRefGoogle ScholarPubMed
28.Hodge, JG Jr, Courtney, B. Assessing the legal standard of care in public health emergencies. JAMA. 2010;303:361-362.CrossRefGoogle ScholarPubMed
29. Kolata G, Longman J, Pilon J. Doctors saved lives, if not legs, in Boston. The New York Times; April 16, 2013. http://www.nytimes.com/2013/04/17/us/physical-legacy-of-bomb-blasts-could-be-cruel-for-boston-marathon-victims.html?pagewanted=all&_r=0. Accessed April 22, 2013.Google Scholar
30.Schultz, CH, Koenig, KL, Lewis, RJ. Implications of hospital evacuation after the Northridge, California, earthquake. N Engl J Med. 2003;348:1349-1355.CrossRefGoogle ScholarPubMed
31.Shagets, FW. Thoughts on the May 2011 Joplin, Missouri tornado. South Med J. 2013;106:113-114.CrossRefGoogle ScholarPubMed
32.Sternberg, E, Lee, GC, Huard, D. Counting crises: US hospital evacuations, 1971-1999. Prehosp Disaster Med. 2004;19:150-157.CrossRefGoogle ScholarPubMed
33.Gray, BH, Hebert, K. After Katrina: hospitals in Hurricane Katrina: challenges facing custodial institutions in a disaster. Washington, DC: The Urban Institute; July 2006. http://urban.org/UploadedPDF/411348_katrinahospitals.pdf. Accessed April 30, 2013.Google Scholar
34.Hartocollis, A, Bernstein, N. At Bellevue, a desperate fight to ensure the patients’ safety. The New York Times; November 1, 2012. http://www.nytimes.com/2012/11/02/nyregion/at-bellevue-a-desperate-fight-to-ensure-the-patients-safety.html?pagewanted=all&_r=1&. Accessed April 22, 2013.Google Scholar
35.Abir, M, Mostashari, F, Atwal, P, Lurie, N. Electronic health records critical in the aftermath of disasters. Prehosp Disaster Med. 2012;27:620-622.CrossRefGoogle ScholarPubMed
36.Agency for Healthcare Research and Quality. Pre-disaster self-assessment. In: Hospital Evacuation Decision Guide. Rockville, MD: Agency for Healthcare Research and Quality May 2010, chapt 2. AHRQ publication No. 10-0009. http://archive.ahrq.gov/prep/hospevacguide/hospevac2.htm. Accessed April 22, 2013.Google Scholar
37.Ankeny, RA. The moral status of preferences for directed donation: who should decide who gets transplantable organs? Camb Q Healthc Ethics. 2001;10:387-398.CrossRefGoogle ScholarPubMed
38.Annas, GJ. The prostitute, the playboy, and the poet: rationing schemes for organ transplantation. Am J Public Health. 1985;75:187-189.CrossRefGoogle ScholarPubMed
39.Browning, CJ, Thomas, SA. Community values and preferences in transplantation organ allocation decisions. Soc Sci Med. 2001;52:853-861.CrossRefGoogle Scholar
40.Brudney, D. Are alcoholics less deserving of liver transplants? Hastings Cent Rep. 2007;37:41-47.CrossRefGoogle ScholarPubMed
41.Egan, TM. Ethical issues in thoracic organ distribution for transplant. Am J Transplant. 2003;3:366-372.CrossRefGoogle ScholarPubMed
42.Kahn, J. The ethics of organ transplantation for prisoners. Semin Dial. 2003;16:365-366.CrossRefGoogle ScholarPubMed
43.McKneally, MF, Sade, RM. The prisoner dilemma: should convicted felons have the same access to heart transplantation as ordinary citizens? Opposing views. J Thorac Cardiovasc Surg. 2003;125:451-453.CrossRefGoogle ScholarPubMed
44.Ubel, PA, Caplan, AL. Geographic favoritism in liver transplantation--unfortunate or unfair? N Engl J Med. 1998;339:1322-1325.CrossRefGoogle ScholarPubMed
45.Ubel, PA, Jepson, C, Baron, J, Mohr, T, McMorrow, S, Asch, DA. Allocation of transplantable organs: do people want to punish patients for causing their illness? Liver Transpl Surg. 2001;7:600-607.CrossRefGoogle ScholarPubMed
46.Weimer, DL. Public and private regulation of organ transplantation: liver allocation and the final rule. J Health Polit Policy Law. 2007;32:9-49.CrossRefGoogle ScholarPubMed
47.Veatch, RM. Disaster preparedness and triage: justice and the common good. Mt Sinai J Med. 2005;72:236-241.Google ScholarPubMed
48.Antommaria, AH, Powell, T, Miller, JE, Christian, MD. Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Ped Crit Care Med. 2011;12:S163-S168.CrossRefGoogle ScholarPubMed
49.Hick, JL, Rubinson, L, O'Laughlin, DT, Farmer, JC. Clinical review: allocating ventilators during large-scale disasters--problems, planning, and process. Crit Care. 2007;11:217.CrossRefGoogle ScholarPubMed
50.Kinlaw, K, Levine, R. Ethical guidelines in pandemic influenza. Atlanta, GA: Centers for Disease Control and Prevention; February 15, 2007. Cohttp://www.cdc.gov/od/science/integrity/phethics/panflu_ethic_guidelines.pdf. Accessed September 24, 2012.Google Scholar
51.Gostin, LO, Berkman, BE. Pandemic influenza: ethics, law and the public's health. Admin Law Rev. 2007;59:121-175.Google Scholar
52.Roberts, M, DeRenzo, EG. Ethical considerations in community disaster planning. In: Phillips SJ, Knebel A, eds. Bioterrorism and Other Public Health Emergencies: Tools and Models for Planning and Preparedness. Rockville, MD: Health Systems Research Inc; 2007.Google Scholar
53.Kuschner, WG, Pollard, JB, Ezeji-Okoye, SC. Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures. Hosp Top. 2007;85:16-25.CrossRefGoogle ScholarPubMed
54.Larkin, GL, Arnold, J. Ethical considerations in emergency planning, preparedness, and response to acts of terrorism. Prehosp Disaster Med. 2003;18:170-178.CrossRefGoogle ScholarPubMed
55.Lo, B, Katz, MH. Clinical decision making during public health emergencies: ethical considerations. Ann Intern Med. 2005;143:493-498.CrossRefGoogle ScholarPubMed
56.Pesik, N, Keim, ME, Iserson, KV. Terrorism and the ethics of emergency medical care. Ann Emerg Med. 2001;37:642-646.CrossRefGoogle ScholarPubMed
57.Sztajnkrycer, MD, Madsen, BE, Alejandro Baez, A. Unstable ethical plateaus and disaster triage. Emerg Med Clin North Am. 2006;24:749-768.CrossRefGoogle ScholarPubMed
58.Gostin, LO, Hanfling, D. National preparedness for a catastrophic emergency crisis standards of care. JAMA. 2009;302:2365-2366.CrossRefGoogle ScholarPubMed
59.Pope, TM, Palazzo, MF. Legal briefing: crisis standards of care and legal protections during disasters and emergencies. J Clin Ethics. 2010;21:358-367.CrossRefGoogle ScholarPubMed
60.Weaver, JC. Appropriate documentation: your first (and best) defense. Ed Legal Let. 2004;15:49-60.Google Scholar
61.Lyons, JM III, Martinez, JA, O'Leary, JP. Medical malpractice matters: medical record M & Ms. J Surg Educ. 2009;66:113-117.CrossRefGoogle ScholarPubMed
62.Szalados, JE. Legal issues in the practice of critical care medicine: a practical approach. Crit Care Med. 2007;35:S44-S58.CrossRefGoogle ScholarPubMed
63.Knowlton, SP. The medical record: treatment tool or litigation device? Adv Skin Wound Care. 2003;16:97-98.CrossRefGoogle ScholarPubMed
64.US Department of Health and Human Services. Can health care information be shared in a severe disaster? US Department of Health and Human Services website; March 14, 2006. http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures_in_emergency_situations/960.html. Accessed September 24, 2012.Google Scholar
65. Access of individuals to protected health information. Public Welfare. 45 CFR 164:524; October 1, 2011. http://www.gpo.gov/fdsys/granule/CFR-2011-title45-vol1/CFR-2011-title45-vol1-sec164-524/content-detail.html. Accessed September 24, 2012.Google Scholar
66.Satel, S. Supply, Demand, and Kidney Transplants. Stanford, CA: Hooper Institution, Stanford University; July 30, 2007. Policy review No. 144. http://www.hoover.org/publications/policy-review/article/6060. Accessed September 24, 2012.Google Scholar
67.United Network for Organ Sharing. Organ allocation. United Network for Organ Sharing website. http://www.unos.org/donation/index.php?topic=organ_allocation. Accessed September 24, 2012.Google Scholar
68. Condition of participation: patient and living donor management. Public Health. 42 CFR 482:94; October 1, 2011. http://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol5/CFR-2011-title42-vol5-sec482-94/content-detail.html. Accessed September 24, 2012.Google Scholar
69. Ethical considerations in the allocation of organs and other scarce medical resources among patients. Council on Ethical and Judicial Affairs, American Medical Association. Arch Intern Med. 1995;155:29-40.CrossRefGoogle Scholar
70.Berlin, L. The duty to disclose. Radiol Today. 2009;10(12):22. http://www.radiologytoday.net/archive/rt061509p22.shtml. Accessed September 24, 2012.Google Scholar
71.US Food and Drug Administration. Protection of human subjects; informed consent; proposed rule. Fed Regist. 1995;60(183):49085.Google Scholar
72.Eyssallenne, AP. How far do you go? Intensive care in a resource-poor setting. N Engl J Med. 2012;367:8-9.CrossRefGoogle Scholar
73.Matzo, M, Wilkinson, A, Lynn, J, Gatto, M, Phillips, S. Palliative care considerations in mass casualty events with scarce resources. Biosecur Bioterror. 2009;7:199-210.CrossRefGoogle ScholarPubMed
74.Daniels, N. Justice, health, and healthcare. Am J Bioeth. 2001;1:2-16.CrossRefGoogle ScholarPubMed
75.Barshes, NR, Hacker, CS, Freeman, RB Jr, Vierling, JM, Goss, JA. Justice, administrative law, and the transplant clinician: the ethical and legislative basis of a national policy on donor liver allocation. J Contemp Health Law Policy. 2007;23:200-230.Google ScholarPubMed