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Nurses' Notes Conflict With EP's? Don't Let It Go Unacknowledged
Succinctly address disagreements
Does the EP's charting indicate that a patient was discharged home, while an ED nurse's documentation states, "The patient looks very sick and I don't think he should be discharged," go unacknowledged without any additional explanation?
If the patient's chart contains an important difference of opinion, like this one, it's a mistake to just ignore it, according to Frank Peacock, MD, vice chief of emergency medicine at The Cleveland (OH) Clinic Foundation. Peacock says that if a bad outcome occurs and the case goes to trial, bias will generally go to the person who knows the most about the patient in this case, the EP. "I'm the guy who did the long H&P and talked to all the consultants, so I have more details to play with," he says.
Peacock recommends succinctly addressing the nurse's statement in this scenario, with documentation such as, "The patient is at baseline. I have read the nurse's notes and do not agree."
The EP may notice that a patient's blood pressure was documented as 50 by the triage nurse, but the patient is moving around and seems fine. In this case, Peacock suggests documenting, "Although the nurse documented the blood pressure as 50, the clinical grounds suggest this is an erroneous measurement."
Be Above Board
A typical situation is that an ED nurse may chart that a patient has chest pain, and the doctor may determine that it's actually abdominal pain, according to Rade B. Vukmir, MD, JD, FACEP, chief clinical officer of the National Guardian Risk Retention Group and chairman of education at Emergency Consultants, Inc., both based in Traverse City, MI, and adjunct professor of emergency medicine at Temple University Clinical Campus, Pittsburgh.
"If that is, indeed, true, and the patient does not truly have chest pain, you could do nothing at all with the documentation and just leave it be. But, that is a high-risk situation," he says.
Anytime you encounter a chart inconsistency, says Vukmir, "it is medicolegally prudent to address and reconcile it. But do it in an above-board manner." An example of this, says Vukmir, would be, "The nursing record suggests that chest pain was the chief complaint, but to my own exam, I found it to be abdominal pain."
"Remember that physicians and nurses, although working shoulder to shoulder, are still two different administrative arms," says Vukmir. Resolving the inconsistency with a nursing peer is, in some ways, better than having an EP do this, adds Vukmir.
If an EP is concerned about an inconsistency, he advises going to the charge nurse. "If you found abdominal pain and the nurse found chest pain, ask him or her to help you reconcile that," Vukmir says. "Ask, 'Would you mind having another nurse go back and do a reassessment to help clarify the situation?'"
Changes in Story
There may be discrepancies between what the triage note says and what the patient later states. For instance, the triage notes report a history of fever, which the patient now denies, or the EP's more detailed history reveals that a patient's severe headache resolved a week ago.
"Patients sometimes misunderstand the line of questioning and want to tell you everything, related or not," says Hartmut Gross, MD, a professor of emergency medicine at Medical College of Georgia in Augusta. "In the din of the ED, staff members may misunderstand what the patient is saying."
Gross tries to pinpoint these misunderstandings, and documents statements such as, "Even though the triage note says ..." or "The patient now adds ..." He also specifically asks the patient about what the triage staff has documented. "It gives the patient a chance to correct what I thought they told me or specifically refute what was documented by someone else," he says.
For more information, contact:
Hartmut Gross, MD, Department of Emergency Medicine, Medical College of Georgia, Augusta. Phone: (706) 721-7144. E-mail: firstname.lastname@example.org.
W. Frank Peacock, MD, The Cleveland Clinic Foundation, Department of Emergency Medicine, Cleveland, OH. Phone: (216) 445-4546. Fax: (216) 445-4552. E-mail: email@example.com.
Rade B. Vukmir, MD, JD, FACEP, Critical Care Medicine Associates. Phone: (412) 741-7018. E-mail: firstname.lastname@example.org.