Missed myocardial infarction (MI) is one of the most common and costly reasons for ED malpractice claims.1,2

“Careful documentation is important in any malpractice case, but especially so in missed MI cases,” says Julie C. Mayer, JD, a partner in the Virginia Beach office of Hancock, Daniel & Johnson.

Mayer’s firm has represented several EPs who were sued by a patient who experienced an MI shortly after discharge. In each case, the narrative notes became vital areas of focus.

Often, the plaintiff’s lab results were borderline or technically abnormal, but not enough to definitively indicate cardiac problems. In those cases, the EP’s charting on their evaluation and thought process became “key in defending against the plaintiffs’ claims that the emergency department physician had ignored obvious signs of a cardiac event,” Mayer reports.

Some charts indicated there was chest pain and an abnormal ECG, but the patient was discharged with no explanation. “Plaintiffs use this to make a case that the EP missed classic presentation of MI,” Mayer explains. EPs can counter this allegation with specific documentation:

The EP’s thought process regarding why it was safe to discharge the patient, even though some signs were consistent with MI. “It is important for the physician to make it clear in their documentation that they have reviewed all findings, but believe based on the presentation that the patient is not suffering from an MI,” Mayer stresses.

Specific reasons why the EP does not believe it is an MI. “This may include referencing objective test results or other potential conditions that are higher up on the differential diagnosis list,” Mayer offers. The chart should include a thorough description of the symptoms, history, and potential non-MI causes of the symptoms.

Specific details on the location and nature of the pain. Only documenting “chest pain” is problematic because it allows plenty of room to later claim the pain suggested an MI. Good specifics can shut down this argument. With details noted in the medical record, “the plaintiff cannot embellish or change the nature of the pain once litigation has started,” Mayer explains.

Test results (including lab results), vital signs, and ECG strips. “It is imperative that the providers document vital signs are within normal limits during examinations, and to make sure that any cardiac monitoring goes into the chart,” Mayer says.

In some malpractice cases, ED providers testified about continually checking the telemetry strips and vital signs. However, there was no proof in the chart. If the providers had written "Reviewed vitals and telemetry monitoring, which were normal," it would have made defending the case years later in court much easier. “Be sure to explain why any abnormal results are not the result of an MI,” Mayer adds.

Discharge instructions (including specifics on when to return to the hospital and who to follow up with). Often, plaintiffs testify they had no idea they needed to return to the ED if they felt worse. Others insist no one mentioned the need for additional follow-up from a primary care provider or a cardiologist.

Any refusals of diagnostic tests or treatment. Sometimes, patients (either for financial reasons or personal reasons) refuse to undergo any additional testing. It is important for the provider to document the patient’s refusal and his or her reasons for the refusal. “After the fact, nearly all plaintiffs will claim that the test was not offered and that if it had been, they would have agreed to the testing,” Mayer says.

If the chart is vague on any of these points, plaintiffs can use these deficiencies as further evidence indicating providers never took the patient’s complaints seriously. Reviewers studying the chart after the fact already know the outcome — the patient experienced an MI right after leaving the ED.

“Their opinions may be impacted by hindsight bias,” Mayer says. “This can be minimized by careful documentation by the providers at the time of care.”


  1. Ferguson B, Geralds J, Petrey J, Huecker M. Malpractice in emergency medicine — a review of risk and mitigation practices for the emergency medicine provider. J Emerg Med 2018;55:659-665.
  2. Brown TW, McCarthy ML, Kelen GD, Levy F. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med 2010;17:553-560.