The COVID-19 pandemic has created an abundance of medical issues for front line providers to be considered in concert with legal issues and malpractice prevention. Not unexpectedly, both medical and legal concerns adapt with available resources and the state of evolving medical knowledge.
Documentation, always key to the practice of medicine and defense of claims, is now even more critical due to experimental treatment options, alternative modes of physician communication with patients, constantly evolving medical diagnostic and treatment possibilities, limited availability of personal protective equipment, potential shortage of medical personnel, need to determine whether procedures are elective, and a host of other challenges posed by COVID-19.
Documentation of medical decisions not only preserves information regarding availability of resources and medical knowledge at the time treatment was rendered, it can also serve to justify the decision to follow a certain course at a given time. Proper documentation may help to alleviate the risk of the care being evaluated in hindsight to the potential detriment of the provider by establishing that good care was provided based on the most current information available.
While the unique circumstances presented by COVID-19 have not changed the necessity for documentation, they have demonstrated the need for a different approach that captures the proposed course of treatment, summarizes communication between the provider and the patient/family, and provides an explanation of any situation that may depart from the typical course. Examples of such situations may include off-label use of medications, decisions relating to the use of ventilators, orders for testing, DNR orders, consents, and risks of treatment/procedures. The ideal is to recreate via documentation the setting where treatment was rendered for a clear understanding in the future of the decision making process and the care taken to communicate and consider treatment options for the patient/family.