Be Direct, But Diplomatic, If Assessment Differs From EP's

Don't include opinions in chart

If nursing assessment conflicts with an emergency physician's (EP), the ED nurse should speak privately with the EP about this, advises Mariann Cosby, MPA, MSN, RN, LNCC, principal of MFC Consulting in Sacramento, CA. Document subjective and objective patient data, what was communicated to the EP and other providers, their response, and then the nurses' actions, she recommends.

"There can be many dynamics underlying the causes and reasons for disagreements," she says. "Diplomatic communication with the EP is often the best place to start."

Often, says Cosby, disagreements arise over discharge orders. The EP may want to discharge a patient who was treated for acid indigestion, with a workup consisting of an EKG, chest X-ray, labs, and some antacid. While attempting to discharge the patient, however, the ED nurse may learn that the patient has increased pain, appears more anxious, and has an elevated respiratory rate.

In this case, says Cosby, the ED nurse should document these findings, recheck the vital signs, and report them to the EP. "Tell the EP of your concerns, and why you are concerned," she advises.

Cosby says that if the EP dismisses the findings and says, "Oh, he comes in all the time with that problem. He has had his medication. Just send him on his way," and the ED nurse is concerned that the patient might be having a cardiac or other event that may warrant further intervention, the nurse should reiterate his or her concerns to the EP.

"The ED nurse should also suggest the EP take one more look at the patient," says Cosby. "This should all be documented as it occurs, in very straightforward language."

Go Up Chain of Command

If the EP insists the patient be discharged, Cosby says the ED nurse should consider going up the chain of command, which would include involving the charge nurse, nurse manager, or other nursing administrative personnel as needed.

"Depending on the circumstances, the nurse's concern may get fleshed out, and the issue resolved," says Cosby. In this situation, Cosby says the ED nurse should be certain to document the conversations that transpired with the providers and nursing supervisory staff, and any interventions that occurred to reevaluate the patient.

"Communicate and document the discharge instructions to the patient," says Cosby. "These should include the reasons indicating a need to return to the ED, and the patient or family's understanding of the discharge instructions."

In rare instances when the ED nurse has communicated his or her concerns with the EP, has started up the chain of command, and still feels uncomfortable with the decision made by the providers to discharge the patient, he or she has a decision to make, says Cosby.

The ED nurse can either follow the EP's orders, says Cosby, or redirect the discharge to his or her superiors. "The ED nurse should never lose sight of his or her duty to advocate for the patient," she says. "Continue to elevate the situation or issue of concern to the next level in the chain of command to ensure safe patient care."

Don't Discuss in Chart

If Ann Robinson, MSN, RN, CEN, LNC, principal of Robinson Consulting, a Cambridge, MD-based legal nurse consulting company, thinks that a really bad judgment call was made on the part of an EP, she doesn't document this in the patient's chart. Instead, Robinson speaks to the physician directly, or goes up the chain of command to report it.

"The chart is not the place for that forum of discussion," says Robinson. "The chart is a reflection of the visit, the evaluation, and what was done. A sit-down with the risk manager would be the time to discuss a difference of opinion between providers."

Robinson says that if there are discrepancies between the nursing and physician documentation, "an astute observer will pick up on that and utilize it to peck away at the credibility of whoever is being deposed."

In one case Robinson reviewed, an ED nurse documented the time she informed a physician of something and when it was acted on. "There was a lag time there. The physician countered that he was certain that the lag time didn't take place, but based on the chart, it sure looked like that was what did take place," says Robinson. "It had a negative impact on the credibility of the testimony of the physician at the time."


For more information, contact:

• Mariann Cosby, MPA, MSN, RN, LNCC, Principal, MFC Consulting, Sacramento, CA. Phone: (916) 505-0446. Fax: (916) 974-0524. E-mail:

• Ann Robinson, MSN, RN, CEN, LNC, Robinson Consulting, Cambridge, MD. Phone: (410) 463-3770. E-mail: