When the patient disagrees with the ED record

What should be done if the ED patient disagrees with what is documented or perceives that the record is incomplete?

These situations might raise questions in the patient's mind, says Chris DeMeo, JD, a health care attorney at McGlinchey Stafford in Houston. Many EDs, for example, use electronic template charting, which can be confusing to someone who doesn't use it on a regular basis. The form might have entry points for numerous system reviews, many of which are noncontributory to the patient's presenting complaint and/or are normal on assessment. Some ED physicians might get into the habit of simply leaving these data points blank, even though they were assessed, because they are not pertinent to the reason the patient is in the ED, says DeMeo.

"A patient who sees that a 'GI,' 'CVS,' or 'Integ' assessment is left blank may be left with the wrong impression that these systems were not examined by the physician," he says.

This misconception is exacerbated by the fact that many patients may not know what a gastrointestinal, cardiovascular, or skin assessment entails, and thus they might not realize that they actually received them, says DeMeo. To address this, the ED physician should comply strictly with guidelines for filling out the forms, which typically require a backslash or other mark indicating that the system was reviewed but was negative, or a check mark in a box that states systems were reviewed but were negative except as documented, he says. Similarly, a narrative note may seem terse to a patient if several systems are not mentioned because they were reviewed but deemed normal or otherwise noncontributory.

Again, DeMeo recommends a simple notation that the systems were assessed but were negative except as set out in the record. "This will assist the physician in explaining to the patient that an assessment was done even if the results are not written out in the record," he says.

In addition, allowing the patient to review the medical record while the ED physician is available to answer any questions reduces the risk of confusion, adds DeMeo.