In the course of malpractice litigation, EPs commonly find themselves on the receiving end of claims that the ED visit was rushed or incomplete. To the frustration of defense attorneys, the ED chart often offers nothing to counter these assertions.

A nurse may tell the EP that a patient is complaining of a headache. When the EP goes in to re-evaluate the patient, the patient says, “I always get headaches like this.”

“Instead of being a worrisome red flag, it turns out to be a benign finding,” says Douglas Segan, MD, JD, FACEP, a Woodmere, NY-based medical-legal consultant.

Since the plan of care isn’t changing, EPs typically won’t document the fact that they went in to see the patient. The nurse, however, has likely documented the patient’s complaint. If a bad outcome occurs, “the last thing you see in the chart is that the patient is now complaining of a headache,” Segan says. The assumption, even if the EP re-evaluated the patient and decided it was something innocuous, is that the EP either didn’t know about the new complaint or did nothing to address it.

“When the physician’s deposition is being taken a year or two later, the worst possible interpretation is given to the chart because there is nothing to contradict that,” Segan says. The EP may have actually checked the patient and discussed the care plan with the family several times during the course of an ED visit.

“There is a big difference between a nursing note saying ‘At 17:00, patient complains of increased abdominal pain,’ and one adding that ‘and the physician is in to re-evaluate the patient,’” Segan says.

While both notes may be factually accurate, “the latter sounds so much better than the former,” he adds.

Documentation showing the patient appeared well before discharge “can make or break a case,” Segan notes. Frequently, an ED patient will present with significant symptoms, and is discharged, but the chart doesn’t reflect the patient’s improvement at the point of discharge. “It may be that their abdominal pain, chest discomfort, or headache went away, and that there were no serious findings on the workup,” Segan explains. “But there needs to be a progress note, which is frequently lacking, showing that.”

Because of time pressure and other patients who require the EP’s attention, “we don’t always do as good a job as we should documenting in the chart that the patient was better when they left the ED,” Segan says. In an infant with fever, for example, the ED chart should ideally include a discharge note by the EP such as, “The patient is happy and playing and drinking well. Parents state the infant is acting normally.”

“This becomes important if it’s the unfortunate situation of the infant developing meningitis or sepsis. People will have different memories of the patient’s condition on discharge when these cases go poorly,” Segan warns.

Set Clear Expectations

Laurie Marcum, RN, senior risk consultant at Coverys, a Boston-based medical professional liability insurance provider, often sees ED charts that fail to document these things:

• A complete and accurate patient history and physical examination.
• That the problem list or medication list entered by a nurse or imported from the last visit via the electronic medical record (EMR) was reviewed by the EP.
• Clinical decision-making related to the diagnosis and treatment plan.

“Extensive use of algorithms, protocols, and T-sheets add to the appearance that little time was spent with the patient,” Marcum says. Such documentation gives the impression that care was provided via a prescribed pathway, rather than being individualized for the patient.

“Best practice risk mitigation strategies for ED physicians include using a clinical narrative to describe the patient’s clinical presentation and the care that was provided,” Marcum offers. A thorough documentation of the ED physician’s thought process will reflect the quality care that was provided.

EMR time stamps are not necessarily indicative of the actual time spent with a patient, but plaintiff attorneys may use these to demonstrate the EP spent only a minute or two with the patient. “The quality of the care provided is the best defense against a time stamp that may, on the surface, suggest that not enough time was spent with the patient,” Marcum says.

She recommends EPs set clear expectations for nurses to timely notify EPs of assessment abnormalities and critical vital signs and lab values, and appropriately document that they have notified the EP and the EP’s response.

“If an ED physician spends an extended period of time at a patient’s bedside or in a 1:1 scenario, such as during a code or procedure, this should be documented by the ED physician and the involved nurses,” Marcum adds.

SOURCES

• Douglas Segan, MD, JD, FACEP, Woodmere, NY. E-mail: dougsegan@yahoo.com.
• Laurie Marcum, RN, Senior Risk Consultant, Coverys, Boston, MA.