Can you prove you told a physician about symptoms?

If you don't document, you could be held liable

If you tell an ED physician that a patient's condition changed for the worse and the patient later sues, can you prove what you said?

A change in condition always should be communicated to the physician, with the time of notification documented as well as the physician's response, says Trish Murray, RN, BN, CEN, ED nurse manager at Houlton (ME) Regional Hospital. "If the nurse doesn't document that they let the physician know, then they have no recourse if the physician doesn't act on the information and the patient condition continues to deteriorate," she says.(See documentation policy.)

Murray gives the following example of good documentation: "BP decreased to 90/70, pt now diaphoretic. Pt placed in Trendelenburg position. Dr. Jones notified of change in condition at 0900, order for fluid bolus received. BP increased to 111/80 after fluid bolus, Dr. Jones notified, in to evaluate patient at 0930."

The ED has a "notifying a physician" policy that addresses this specific issue. It is the result of a chart review in which a change in condition was reported to the physician and acted on, but with no documentation that the notification occurred. The policy states that the ED or attending physician will be notified by nursing staff when a patient experiences a change in condition including deterioration in vitals sign, decreased level of consciousness, change in mental status, and increased pain. The policy also states that this verbal notification will be documented in the record by the nurse and will include the time of the notification and the name of the physician notified.

"Sometimes in the busy ED environment, we take things for granted, like our interactions with physicians," says Murray. "Things can happen so fast, so the policy was put in place as a reminder to staff."

Document the patient's vital signs, any associated signs, symptoms, or other clinically important conditions, and any actions that you have carried out, says Jeff Strickler, RN, clinical director of emergency services at University of North Carolina Hospitals in Chapel Hill. "Ideally vital signs should be verified, with documentation of what method was used to take them," he says.

When documenting, answer three questions, says Strickler: Who was told, when they were told, and how they were told. For example: "Dr. Smith notified via phone at 1810 that patient BP 80/50, checked x 2 via NIBP."

"Think in bullet points" when conveying a change in a patient's condition to the physician, advises Jennifer Williams, RN, BC, CEN, CCRN, clinical nurse specialist for emergency services at Barnes-Jewish Hospital in St. Louis. "Give the physician a one-sentence situation update, one sentence on background, and one sentence on your current assessment. Then ask for the plan," she says.

The ED implemented the "SBAR" approach, which stands for Situation, Background, Assessment, Response, and Recommendation, for communicating critical information between health care providers.

Williams gives the following example to say to the physician: "Dr. Smith, I have a 62-year-old female with chest pain. She has been started on nitro and heparin, aspirin is given, currently chest pain is 7/10 and was a 4/10 on arrival. Vitals are now HR 112, BP 88/50, RR 22, and pulse ox is 95% on 4L Nasal Cannula. This represents a change from initial vitals of HR 88, BP 110/60. I have held the nitro drip due to her blood pressure. What would you like done if her blood pressure and heart rate continue to change? What is your threshold for implementing the plan?"

Include the name of the physician you spoke with, the time, what you communicated, what their plan was, and what actions you have taken, suggests Williams. She gives the following example: "Updated Dr. Smith at 2316 on patients decreasing blood pressure and increased heart rate. Informed nitro drip was on hold. Dr. Smith ordered additional IVF and to hold nitro until blood pressure stabilizes above 120 systolic. IVF bolus initiated. If vitals continue to deteriorate, Dr. Smith to be notified for additional treatments."

"After you initiate the actions, document the patient's response and that you communicated the results to the physician," says Williams. "If they do not want to initiate any treatments, this should be noted as well." For example: "IVF Bolus completed, patient now with BP 126/72, HR 88. Nitroglycerin infusion restarted at 3 mcg/min and will monitor vital signs. Patient reports pain is 5/10 at this time. Dr. Smith notified of improvement in patient condition at 0040, and no further treatment ordered at this time."

Sources

For more information on communicating changes in a patient's condition, contact:

  • Trish Murray, RN, BN, CEN, Nurse Manager, Emergency Department, Houlton Regional Hospital, 20 Hartford St., Houlton, ME 04730. Telephone: (207) 532-9471. E-mail: tmurray@houltonregional.org.
  • Jeff Strickler, RN, MA, Clinical Director, Emergency Services, University of North Carolina Hospitals, 101 Manning Drive, Chapel Hill, NC 27514. Telephone: (919) 966-0068. E-mail: JCStrick@unch.unc.edu.
  • Jennifer Williams, RN, BC, CEN, CCRN, Clinical Nurse Specialist, Emergency Services, Barnes-Jewish Hospital, Mail Stop 90-21-330, St. Louis, MO 63110. Telephone: (314) 747-8764. E-mail: jaj5264@bjc.org.