Ms N was a nurse practitioner (NP) working in a primary care practice with several physicians and licensed practical nurses (LPNs). She had been working at the practice for over a decade and saw her own patients.

In late October, a new patient came into the practice seeking a primary care medical provider and Ms N saw the patient as part of a new patient visit with the intention of becoming his primary care provider. The patient, Mr S, was 57 years old. At the initial appointment, his blood pressure was 164/96 mm Hg. Ms N asked the patient to return in a month for a full physical.

At the beginning of December, Mr S returned to the practice for a comprehensive care visit. His blood pressure at this visit was 176/94 mm Hg at 8:05 am. Ms N told the patient to relax and she would recheck his blood pressure towards the end of the appointment. However, when she retook his blood pressure at 8:25 am, it had risen to 179/100 mm Hg. Ms N prescribed lisinopril-hydrochlorothiazide to the patient to control his blood pressure and asked him to return in a week for a blood pressure check to assess whether the medication was helping.

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The patient returned a week later to have his blood pressure taken. The patient did not see Ms N on this occasion; an LPN conducted the blood pressure check and recorded the measure as 140/110 mm Hg. The LPN conveyed the results electronically to a physician in the office. The physician responded electronically and wrote “systolic much improved but diastolic still high, would recheck in 1 to 2 weeks and if still elevated then increase lisinopril.”

Three days later, Ms N electronically reviewed and approved the LPN’s report but did not order more testing or a change in treatment.

In mid-December, the patient was taken to the emergency department with an altered mental status. He was diagnosed with hyponatremia and was admitted. The next day he had a cardiopulmonary arrest in the hospital’s intensive care unit. Mr S was revived but he had a hypoxic event, which caused permanent cognitive impairment. He would need care for the rest of his life.

Two years later, the patient’s family filed a lawsuit against the NP, alleging medical negligence. Specifically, the plaintiffs alleged that Ms N had breached the standard of care in her treatment of Mr S causing the patient harm.

Ms N sought the counsel of a defense attorney who filed a motion to dismiss the case, claiming that it was not timely filed and was out of the state’s 2-year statute of limitations on medical malpractice cases. The trial court agreed and granted summary judgment in favor of Ms N, concluding that the nurse practitioner did not provide care to Mr S after December 1, and thus the complaint was filed 3 days past the statute of limitations and should be dismissed.

The patient appealed, contending that the trial court had erred in dismissing the case against Ms N. The case went to the appeals court.

Ms N characterized her approval of the report as merely administrative and done simply to close an open note in the medical record. The only response to Mr S’s December 8 visit was the LPN’s note and the physician’s electronic response, noted Ms N; this “administrative” act did not constitute the provision of health care. She also argued that since she did not see Mr S face to face after December 1, her act of signing off on the report could not be considered health care.

The appeals court disagreed, first by pointing out that the wording of the state’s medical malpractice act concerns health care that was provided or “that should have been provided, by a health care provider, to a patient.” They noted that even if Ms N had not actually seen the patient after December 1, the evidence showed that December 11 was the final opportunity she had to evaluate the patient’s latest test results and order further testing or treatment.

The appeals court held that the 2-year statute of limitations begins to run not necessarily on the last date that the health care practitioner actually saw the patient face to face, but on the last opportunity that the health care practitioner had to monitor, diagnose, or treat the patient (or fail to do any of these things). The appeals court ruled that it could be viewed that Ms N provided (or failed to provide) health care by signing off on the LPN’s note on December 11. The case was remanded back to the trial court for a trial on this issue.

Protecting Yourself

Whether or not Ms N will ultimately be found to have violated the standard of care is another matter that will be up to a jury. The jury may decide that she had the responsibility to act on the patient’s blood pressure numbers or it may decide that she had acted properly in her scope of practice.

When an NP or PA signs a report, they are acknowledging that they have looked at it and processed it. They are taking responsibility. These are not just administrative tasks; be very careful about signing something that you have not thought through and made a decision about how to proceed. Ms N’s signing off of the LPN’s report for “administrative” reasons could have a long-reaching effect on her professional future.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.