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How should a serious condition discovered in a retail clinic be documented in the patient's EMR

By Troy Bundy to EMR/EHR


In this segment, Healthcare Matters interviews ALL MD attorney Troy Bundy about how to document a serious condition discovered in a retail healthcare clinic.

Bundy is a hiring partner at Hart Wagner LLP in Portland, Ore., where he defends healthcare professionals against claims of malpractice, cyber-liability, HIPAA and DEA investigations, health-related business formation and contract resolution, licensing board matters, billing disputes and privileging issues.

Bundy is a charter member of the Association of Liability Lawyers in Medical Defense (ALL MD), a nationwide organization that connects healthcare providers with attorneys who specialize in medical malpractice defense.

Question 2 of 5

Interview was recorded October 14, 2015


Mike Matray: Hello and welcome to Healthcare Matters, where the medical and legal communities come together to discuss healthcare matters. I’m your host, Mike Matray and today’s guest is Troy Bundy. Mr. Bundy is a hiring partner at Hart and Wagner in Portland, Oregon where he has been defending healthcare professionals since he joined the firm in 1996. Welcome to the show, Troy.

Troy Bundy: Thanks, good to be here.

Mike: All right. Well, one of the major differences is I, too, have been to a retail health clinic and it was a nurse practitioner and physician’s assistant. There was no actual MD or OD on site. One of the things I noticed would be that what if a more oppressing health matter is discovered in a retail clinic? How would they know in the electronic health record or the traditional medical record that they referred the patient to an actual MD or cardiologist and how would that stand up in court?

Troy: Well, I think in any clinic setting, especially in urgent care, you’re going to have physician’s assistants that provide some of the care or perhaps nurse practitioners. The reality is, when it comes down to litigation, even though we’d just like to say, “Well, the PA met the standard of care as it refers to other P.As in the community”, that is usually not how it goes. The PA is going to be doing work that a licensed MD will perform and therefore I think that most juries are going to hold the PA to the higher standards that are required. So, routinely in my cases where I am defending PAs or NPs, my standard experts are going to be Internists or Family Practitioners or Emergency Room Physicians, whatever the case may be.

I think that is really the standard that is being employed despite the jury instruction that is supposed to be the same medical specialty with training and experience. As far as referrals, they need to be well documented in the chart. That’s really all the referring clinician can do, is make sure that the referral documentation is well set out, both in the order and the progress note and then, most of the time there is going to be a patient take home of some kind that will have instructions. They usually say something along the lines of, “I’ve recommended that you see a urologist for this problem” or, “I’ve recommended that you follow up with your regular primary care provider in regard to your sugars” or whatever the case may be. I think documentation is always the linchpin of any medical malpractice case at least.