By Patricia Y. Miller, RN, Esq.
UCLA Health System
Are you familiar with the documentation requirements for your department? Do you have an obligation to review and sign off on residents’ notes? Does the documentation in the record reflect your plan of care? If you never reviewed, how do you know? Unfortunately, in one recent case where the medical care could be explained, the matter was settled due to insufficient documentation — which a good plaintiff attorney can characterize as sloppy and inattentive care.
A 40-year-old male presented to the emergency department with swelling in his left leg, cyanotic toes at the tip, and decreased sensation to light touch. He reported pain in the foot that woke him from sleep, and stated that he had had symptoms for a period of time, although the pain had increased recently. When the patient was found to have a large, near-occlusive thrombus of the aorta and left lower extremity ischemia, a heparin drip was started and a cardiology consult ordered. A day after the completion of the cardiac assessment, the attending elected to proceed with thrombolysis rather than surgery in an attempt to dissolve the clot and salvage the leg. Although the patient underwent numerous procedures over the course of a few weeks, he subsequently required a below-the-knee amputation (BKA). The plaintiff contends that the attending’s failure to act in a timelier manner caused him to lose his leg, and maintained that had the thrombolysis been started 36-48 hours after admission, the limb probably would have been saved.
In this case there was a lot of evidence supporting the physicians’ care. The risk of a BKA was substantial, considering the patient’s severe ischemia. The patient had a known hypercoagulopathy. Once the attending elected to do the thrombolysis procedure he brought the patient back to the cath lab for four procedures over a period of approximately 72 hours and the patient did regain a palpable pulse, suggesting improvement in circulation. An expert even opined that the severity of the disease process in a case such as this statistically produced poor outcomes, including amputations and shortened life expectancy.
Why, then, did we reluctantly settle? The documentation — or lack thereof.
While the attending had detailed procedure notes, there was no documentation of his daily assessment or plan, or evidence that he reviewed or signed off on the fellows’ and residents’ care. This may have been explained had the vascular fellows and residents documented the plan of care and their assessment of the patient’s neurological findings; however, while there were daily notes by the service confirming the patient was seen, the notes were not reflective of ongoing limb assessment and plan. And to complicate matters, there was inconsistent, missing, or lack of documentation in other services, including nursing.
What lessons can be learned?
• Know what is expected of you. Review department and hospital requirements. Medical Staff Policy 112 requires that attendings document at a frequency appropriate to the patient’s condition or change in condition, or reflected within the resident’s progress note. The Policy also states that residents’ notes in the chart should reflect their ongoing consultation with the attending physician and the attending physician’s approval of the treatment. For patients who have undergone a surgical procedure, Medical Staff Policy 112 requires an attending surgeon to document involvement in the post-operative care of the patient by at least one personally documented note – and per the policy, the immediate post-operative note will not suffice for this purpose. In most lawsuits where documentation is an issue, a good plaintiff’s attorney will ask for these policies and attempt to show that slipshod documentation was reflective of the overall care.
- Document. The record should reflect the plan of care, when the plan changed, and why. Residents and fellows can best protect themselves by discussing the plan and any changes to the plan with the attending, and then documenting these discussions. At a recent jury insight program, potential jurors recognized that documentation may be a team approach but expected that the attending would at least review the record, especially knowing that it may be written by a trainee. Be aware, too, that electronic data may be examined to confirm the degree of an attending’s oversight.
- Use of templates. Templates by a service can be very helpful, but they should focus the physician to the critical aspects of that service’s assessment. In this case, a template was in use; however, the residents and fellow didn’t consistently assess the critical nature of the impacted limb (movement, pulses, pain). Rather, the documentation addressed more routine elements of care (lungs, heart) — which, while important, were not the focus of the underlying complaint.
- General pointers. No cutting and pasting, and if you didn’t see an event, do not document it like you personally witnessed it. Finally, be cognizant of nursing documentation. If inconsistent with physician’s documentation, it can be used to discredit the team and demonstrate a lack of communication.