Documentation: Gap in Obstetrics Record Requires Appeals Court to Sort Out "Who Did It?"

January 2, 2019 | Risk Management News

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In a case involving a newborn's birth injury, a Michigan court of appeals reversed a lower court's denial of a hospital's motion for summary judgment, resolving a dispute over who placed an intrauterine pressure catheter (IUPC) during the mother's labor. The appellate court agreed with the hospital that evidence was sufficient to show that the device was inserted by the defendant obstetrician, and not by the hospital's employee, a labor and delivery nurse. The factual/legal dispute arose because documentation of the events of labor and delivery in the electronic health record (EHR) did not identify who inserted the IUPC. The appeals court also rejected the plaintiff's "but for" factual causation argument that had the labor and delivery nurse gone up the chain of command to put a stop to the insertion of an IUPC, the infant's severe brain injuries would not have occurred.

The allegations of malpractice focused on events beginning when the nurse recorded "Visit Dr. Russell." The record documented...

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