Many EPs use boilerplate documentation to indicate they saw, and agreed with, everything ED nurses charted, such as, “Nursing notes reviewed and agreed unless discussed.”
“Blanket statements like that, in general, are not good practice. If something bad happens and you end up in a deposition, it’s very difficult to talk your way out of it,” says William J. Naber, MD, JD, associate professor of emergency medicine at the University of Cincinnati.
One problem is patients might give a different history to ED nurses and EPs. A patient tells the nurse about chest pain. When the EP comes in to evaluate the patient, she only mentions abdominal pain. If the chest pain is not investigated, and the EP’s chart states he or she agreed with the nursing notes, “it creates a very challenging position for the EP to be in if something goes awry,” Naber explains.
Another issue is nurses might document after the EP discharges the patient. “They may do an entry, based on the last thing they talked about, and it may be something unique or different about the visit that the provider would not know,” Naber observes.
The EP has discharged the patient, and assumes the interaction with the patient is finished. If the patient came in with chest pain, labs and ECG returned normal, and is discharged home, the patient may mention something to the nurse on the way out about the pain returning or changing. If the EP does not see the nursing note, and does not investigate further, but the chart indicates the nursing notes were reviewed, “that’s a very difficult statement for a provider to talk around,” Naber cautions.
In one recent deposition, an EP defendant indicated disagreement with the nurse. The plaintiff attorney noted the EP had “agreed” with the nurse in the templated statement. “I’d much rather be in a situation, if asked in a deposition by counsel if I reviewed the nursing notes, to say, ‘My standard practice is to review the nursing notes,’” Naber offers.
That statement allows the EP to talk about the notes, but does not imply the EP agreed with the notes. But there are times when it becomes painfully obvious the EP never read the nursing notes at all. “Sometimes, the EHR’s audit trail is pulled and it shows that the EP provider did not review the nursing notes — when that EP provider’s own note states that the nursing notes were so reviewed,” says Alexandra Dare Essig, JD, a principal at Goodman Allen Donnelly in Glen Allen, VA.
In other cases, the EP only read part of the notes, but missed an important piece of information, reviewed notes of only some nurses, or reviewed the notes hours after the patient was discharged. Essig also has seen episodes in which an EP testified the nursing notes were read, but the audit trail indicated otherwise. One EP claimed to have read the nursing notes, but was unaware the patient registered a worrisome National Institutes of Health Stroke Scale score — or that such a test was performed at all.
The nurse testified the EP was informed of the results, and the documentation supported it. The Stroke Scale score was at odds with the physical exam conducted shortly before, which revealed no neurological deficits. By taking no action to rectify the discrepancy, claiming the nursing notes were reviewed appeared suspicious.
Instead of relying on template charting, systems could require the EP to type in the name of the nurse whose notes were reviewed. “The system could also flag each nursing note actually reviewed by the EP as being reviewed, whether it was a progress note, ancillary event note, or flow sheet,” Essig suggests.
When EPs state “nursing notes reviewed,” they are including everything contained in the notes, says Tracie Dorfman, JD, an attorney at Hancock, Daniel & Johnson in Fairfax, VA. “If the nursing notes contain something contrary to the doctor’s own assessment, that can be fatal in a later malpractice claim,” she cautions.
The EP’s defense might be the EP was unaware of a certain piece of information. If it was contained in the nursing notes, and the chart states “nursing notes reviewed,” then “that defense goes out the window,” Dorfman says.
Instead of making blanket statements about review of nursing notes, the EP should document accurately. “If the doctor did not actually review the nursing notes, stay silent on it,” Dorfman warns.