When You Did It and You Documented, but Others' Charting Differs

Acknowledge discrepancies before lawyer does

[Editor's Note: This is the second of a two-part series on documentation and ED liability. This month, we cover liability risks when the ED physician or nurse's documentation is inconsistent with documentation by other caregivers. Last month, we reported on the legal risks of inadequate documentation and information that should not be omitted.]

What if a crucial aspect of patient care is documented by more than one ED caregiver, and the two accounts conflict?

"If there is one theme to teach staff in an emergency department regarding charting, it would be consistency," according to Linda M. Stimmel, JD, a partner with the Dallas, TX-based law firm of Stewart Stimmel. "It is much easier to defend a lawsuit when the staff charts in the same or similar manner."

Stimmel defended one case where a patient's wound or bed sore was described completely differently by two nurses who saw the patient with the same hour. One nurse used the size of a coin to describe the size of the wound, and another used inches.

"The inconsistency in the chart was used by the plaintiff's attorney to show how no one was really paying attention to the wound on the patient," says Stimmel. "In actuality, everyone was looking at the same wound, but they did not have a consistent way that had been agreed upon to describe bed sores."

Other discrepancies involve the use of different types of graphic records, with some nurses using a slash in a box, others circling a box, and some placing an X in the box. "Many times, they do not remember what that meant two years later when they are looking at the chart," says Stimmel.

For this reason, Stimmel says that her advice as a defense attorney is for ED staff to agree on a consistent way of charting.

"It does not matter which way you choose to chart. Just make sure everyone uses the same, consistent types of terms and descriptions for charting," she says. "This is very important in charting vital signs."

Review Nursing Notes

Discrepancies often occur between ED physician charting and nursing notes, says Gabor D. Kelen, MD, director of the Department of Emergency Medicine at The Johns Hopkins University in Baltimore.

"For some reason these days, nursing now documents more than anything I learned in medical school," says Kelen. "They do their own history and physicals and they do all sorts of assessments. Sometimes those assessments are different than what the physician assessment is, but if you don't read the nursing notes you have no idea."

For instance, the nursing notes may state that the patient had a pain level of 10, with substernal piercing chest pain for the last two hours, with dizziness. "The doctor may say that the patient's toe was stubbed. If that patient goes out and has a myocardial infarction, it looks like the nurses picked it up and you didn't."

In this case, you need to document some type of explanation as to why the nurses got one type of history and you got another. "Otherwise, the discrepancy will kill you every time," says Kelen.

Kelen has seen many cases where the nurse's notes were helpful to a plaintiff. In these cases, the physician's charting appeared as though the ED physician either didn't see, or didn't understand, what the nurse had charted.

"If nurses say the belly was tender and the physician writes that it was nontender, and it turns out to be some abdominal catastrophe, they'll take the nurse's side on that every time," says Kelen. "The attorney will ask, 'Doctor, how carefully did you examine the patient?' And that is a tough explanation in court."

Instead, document something that shows you looked at the nursing notes and acknowledged the discrepancy, such as "I noted the nurse's notes. I believe she was wrong," or "By the time I examined the patient, the exam was pain-free."

Also, if the nurse's triage note says there was a complaint of chest pain, but when you interview the patient you get a different chief complaint, you still need to explain the original complaint that was documented. "I've seen a large number of suits based on unaddressed findings or complaints noted by another member of the health care," says Kelen. "The attending of record must document something—even if it's just 'patient now denies original complaint.'"

Sources

For more information, contact:

• Michael Blaivas, MD, RDMS, Vice President, Emergency Ultrasound Consultants, Bear, DE. Phone: (302) 832-9054. Fax: (302) 832-0809. E-mail: mike@blaivas.org.

• Leonard Bunting, MD, FACEP, Assistant Professor of Emergency Ultrasound, Wayne State University, Detroit, MI. Phone: (313) 745-3330. E-mail: Leonard.Bunting@stjohn.org.

• Robert B. Takla, MD, FACEP, Chief, Emergency Center, St. John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7071. E-mail: rtakla@comcast.net.