Case In Point: Could documentation have prevented this lawsuit?

By Barbara Bellione

The patient is a 65-year-old married man with three grown children, who spent most of his life as a steamfitter.

He later retired, however, due to disability from rheumatoid arthritis. Following his retirement, he worked as a part-time school bus driver.

At the initial visit to the chiropractor, the patient reported having a right hip replacement approximately four years prior to the visit. His chief complaint was pain on both sides of his lower back. He also reported recent cardiac surgery with resultant weight gain and requested a rehabilitation program.

The chiropractor examined the patient and diagnosed him with a sacroiliac sprain. The chiropractor applied mechanical traction to the lower lumbar spine utilizing flexion distraction technique. He also devised a rehabilitation exercise plan, as requested, for the patient.

The patient returned a week later claiming he was still suffering from lower back pain. The chiropractor applied electrical muscle stimulation, trigger point therapy, and mechanical traction. During stretching, the patient’s right hip dislocated, resulting in excruciating pain.

The chiropractor called an ambulance and the patient was transported to the hospital where he underwent a closed reduction of the right hip under anesthesia. He remained in the hospital for two days.

Following the operation, the patient was required to wear a hip brace for 12 weeks. During this time, he was unable to work, drive, or engage in any meaningful activities.

The patient hired an attorney and 10 months after the incident, a lawsuit was filed against the chiropractor. The patient alleged the chiropractor provided a negligent performance of chiropractic treatment, which resulted in a right hip dislocation.

Following the claim, the chiropractor admitted that he gently stretched the area involving the right hip, but did not manipulate it. However, the “gentle” stretching the chiropractor described would not sound gentle to a layperson jury.

Not only that, the chiropractor failed to document the type of stretching procedure he performed in the patient’s record, and it was undisputed that the dislocation occurred when the chiropractor stretched the claimant’s hip. As a result of this injury, the patient incurred over $12,000 in medical expenses and lost approximately $3,500 in wages because of the dislocation.

The patient was later able to return to his part-time job, but only after the brace was removed. He was also able to return to all of his pre-dislocation activities. The patient, however, still continues to suffer pain when walking for long periods of time.

Although the patient demanded $120,000 to settle the claim, the defense team agreed that this would be very difficult to defend and a reasonable settlement should be attempted. As a result, negotiations ensued, and the claim was settled for $60,000.

Barbara Bellione is the director of risk management for the OUM Chiropractor Program (www.oumchiropractor.com), provider of professional liability insurance underwritten by either PACO Assurance or PICA.

DISCLAIMER: This column is provided for educational purposes only. The information presented is not legal advice.

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Learning points

• Obtain and document a thorough medical history prior to performing treatment on a patient. It could prove as a primary defense against allegations of malpractice.

• Review the patient’s medical history for any contraindications to treatment prior to initiating a plan of treatment. This could show the patient had problems prior to the claim.

• Note contraindications in a prominent place in the patient’s record and review prior to each treatment. Make sure documentation is legible, accurate, clinically relevant, chronological, objective, clear, complete, and specific.

• Thoroughly document treatment performed at each visit. Documentation should include: Exact treatment performed, location of treatment, and patient’s response to treatment.