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The following statement was documented by an obviously frustrated EP, one who failed to realize the medical/legal implications of what he was charting: “This drunk, disheveled, foul-smelling patient shows up yet again demanding narcotics and being generally obnoxious.”
“If the patient has an untoward event in the ED or after discharge, statements like this in the medical record render the chart indefensible,” cautions John Shufeldt, MD, JD, MBA, FACEP, principal of Scottsdale, AZ-based Shufeldt Consulting.
Inappropriate comments about patients are surprisingly common in ED charts. One EP charted, “This morbidly obese, drug-seeking indigent showed up again today demanding narcotics.” Another documented, “Given the patient’s profound stupidity, one wonders how he has survived this long.”
Documenting the patient’s exact words is a better way to tell the story, according to Shufeldt. The EP should document “Patient states, ‘I drank a 12-pack, then started to have abdominal pain’” instead of “Intoxicated patient is complaining of abdominal pain.”
Other ED charts included statements depicting ED nurses as incompetent. Some comments were specific on the timing of events during ED visits, which can bolster allegations that care was delayed. One EP charted, “The patient waited for over an hour before the nurse saw fit to answer the call light.” EMR time-stamping already makes the timing of events clear without the insulting remarks. “The order is timed, and the medication or treatment is timed,” Shufeldt notes. “That speaks for itself.”
Another EP charted, “But for the nurse’s gross stupidity, the patient would be alive today.”
“My mantra is, ‘Never fight battles in the medical record,’” Shufeldt offers. “Finger-pointing always ultimately gets the finger pointed back toward you.”
Inappropriate documentation is used first to embarrass the provider at the deposition, then (if the case goes to trial) in front of a jury. “Basically, it impugns the provider,” Shufeldt adds.
Other statements target consultants or other physicians. One ED medical record included this statement: “Unfortunately, due to the anesthesiologist’s incompetence, the patient died during the procedure.” Another angry EP wrote, “I repeatedly told Dr. X not to send the child home.”
“These statements can be used to bring a physician into the case, and they can be used to hang the physician,” Shufeldt warns.
Sticking to the facts is less risky legally and expresses the same point. For instance, an EP might be frustrated that a consultant refuses to come in to evaluate the ED patient. That EP might chart: “I called Dr. Cardiologist at 10:00, 10:15, 10:20. She returned my calls at 11:00. She advised. ...”
The bottom line is that factual statements, or words stated by others in quotations, are better than judgmental ones. “Angry charting never works in the best interest of the provider,” Shufeldt says. “Physicians should avoid it at all cost.”
Christopher B. Colwell, MD, often sees angry charting in ED medical records. This always complicates the defense. “I have seen some outright horrendous statements written that are demeaning to patients,” says Colwell, chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center.
One EP charted, “The patient is an entitled dirt bag who doesn’t deserve to be here.” Another charted, “The patient is an obnoxious drunk who comes in once again complaining of chest pain.”
Charting while angry is dangerous for the EP, according to Colwell. The EP writes things he or she may regret later, which then become part of the ED medical record. Instead, Colwell says to “document in a descriptive way that tells a story that can only have one ending: the one you determined was most appropriate under the circumstances you were faced with.”
Regardless of how frustrating a particular case is, documentation should convey the EP’s calm, thoughtful decision-making. “That is going to help the defense of any future malpractice claim,” Colwell adds.
Financial Disclosure: Kay Ball, PhD, RN, CNOR, FAAN (Nurse Planner), is a consultant for Ethicon USA and Mobile Instrument Service and Repair. The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor), Stacey Kusterbeck (Author), Jonathan Springston (Editor), Jill Drachenberg (Editor), Amy M. Johnson, MSN, RN, CPN (Accreditations Manager), and Leslie Coplin (Editorial Group Manager).