COVID-Related Claims: Best Defense Strategies for Documentation

Protection from COVID-related claims comes down to effective risk management practices.

One of the most important elements in defending medical care is documentation. As the healthcare community deals with another surge of cases, it is important to make sure documentation supports your organization’s efforts. To best protect your Health system or Hospital from COVID-related claims during this pandemic, we compiled a list of documents important to retain and have available. The items and information on this list may be essential in refuting allegations raised in future claims. The list also includes recommendations for information to make part of your command center’s daily functions and as part of your pandemic surge responses.

Record of Governmental and Regulatory Guidance

  • Copy on file of all federal and state public health emergency orders.
  • All guidance coming from CDC (e.g., Prepare to Care Planning Resource, PPE, medications, treatment options, updated symptoms lists).
  • All guidance coming from CMS (e.g., Coronavirus (Covid-19) Partner Toolkit).
  • All guidance coming from the State (e.g., Surge Licensing, PPE Measures, Patient Treatment Protocols).
  • Governors’ executive orders.
  • State liability immunity statutes.
  • U.S. Department of Health and Human Services Public Readiness and Emergency Preparedness Act Protections (PREP Act) and Advisory Opinions regarding COVID-19.

Documentation Supporting Organizational Pandemic Responses

  • Adherence and adjustments to pre-established Emergency Management Plan(s).
  • Record of communication and coordination with key community partners.
  • Reasonable steps taken to adhere to the current and applicable “standard of care.”
  • Infection control practices and procedures implemented. This is particularly important when based upon CDC/HHS guidance.
  • Details of staffing issues potentially impacted services (e.g., shortages related to the Department of Health contact tracing mandated quarantines)
  • A detailed record of the institution’s Delivery System Emergency Management Plan or Incident Command Decisions.
  • Copy of all policies and actions taken to minimize exposure to staff (e.g., fit testing, policies regarding not coming to work if symptomatic);
  • Document staff training on PPE and precautions to reduce any delay in treatment (e.g., response to urgent condition).
  • Record of any PPE shortages or rationing and efforts undertaken to overcome or adjust to the same.

Documentation Supporting Patient Care Efforts

  • Detailed EMR documentation for care impacted by the pandemic such as availability of resources or referral options, and patient decision-making affected by issues created by the pandemic.
  • Record of turnaround time on outside lab results for COVID testing.
  • Discussion of Informed consent issues including the possibility of false negatives, risk of exposure to others, and retesting if symptomatic.  
  • Tracking of elective or non-urgent medical procedures requiring rescheduling due to COVID and communication log of efforts to maintain contact with the patient to identify deterioration or other changes in condition requiring sooner or emergent intervention.
  • Exposure mitigation efforts in place to test patients before placing them in shared rooms where they could be exposed to COVID-19.
  • Document patients who leave AMA relative to COVID-19 treatment (some patients have been demanding certain medications or unavailable treatments).
  • Efforts undertaken to transfer patients to higher acuity care when receiving facility is unable to accept.

Thorough documentation of COVID-19’s impacts on healthcare organizations and the efforts to respond are likely to be an important tool in defending medical care provided during and following the pandemic. Taking the time to ensure the necessary processes are in place and needed information is collected will increase the protections against medical professional liability claims in the future.

If you have any questions or need additional guidance on this list, please contact MPIE Risk or Claims departments. We are happy to discuss this with you.