EP Given Misleading Info About Complaint?
After an ED patient complained of knee problems and the triage nurse recorded a chief complaint of knee pain, the EP diagnosed a musculoskeletal injury. Just before discharging the patient, the EP saw the patient appeared unsteady and, ultimately, diagnosed a subdural hematoma.1
Fortunately, this case was a "near miss," but many malpractice claims involve a patient's bad outcome from an unrelated condition after a previous ED visit. These claims often occur despite the fact that the care given in the ED was appropriate.
Pamela S. Gilman, JD, a partner in the Boston office of Barton Gilman, has handled several such cases. "It never looks good when you have timing issues, but the patient could just as easily have died from a motor vehicle accident after being seen, for which the provider would not be blamed," she says. She recommends these practices to reduce legal risks:
• Note findings of other caregivers in the chart.
One malpractice claim involved a patient who came to the ED with concerns about a possible post-surgical superficial wound infection. "The patient was discharged and died of an infectious process 10 days later," says Gilman. The triage notes became a focus during litigation, since these indicated there was evidence of pus, while the ED nurse and EP indicated in the chart that they found no evidence of an infection.
The case, which resulted in a defense verdict at trial, would likely not have even been filed if the ED nurse or the EP noted that they saw the triage nurse's note and considered it, says Gilman.
The EP could have documented, for instance, "Triage nurse noted pus. We fully evaluated the patient and found no evidence of pus or any other signs of an infection."
This charting would have countered the plaintiff attorney's assertion that the patient's complaint was not addressed, says Gilman. "Instead, we were left after the fact saying, 'We knew that, but we didn't note it,'" she says.
Patients commonly give information about their complaint to multiple providers — the triage nurse, the ED nurse and the EP, and may describe their symptoms differently each time. "The EP should always review and acknowledge all of the information that is recorded that differs from what he or she has been told," Gilman advises.
• Put the patient's words in quotes.
Instead of documenting, "Patient complains of infection," the triage nurse might document "Patient says, 'I think the wound edges look red,'" for instance.
"There is probably no better defense when a patient alleges that his complaint was not addressed than to document the patient's specific complaint," says Gilman.
• Include write-in entries when using template charting.
Gilman says to supplement templates with specific patient information when appropriate, as opposed to simply checking off boxes. "If the nurse or physician adds in some of their own words, it confirms that they were caring and thorough," she says.
• Re-evaluate the patient's condition before discharge if the patient is in the ED for a long time.
This is a simple and quick way to show that the patient was stable at the time of discharge, "but it is not routinely noted," says Gilman. If a patient waits in the ED for hours, a plaintiff's attorney can argue that the patient's condition changed while in the ED.
If someone has an unfortunate medical condition that coincidentally develops soon after discharge, the patient will have an uphill battle arguing that he or she shouldn't have been discharged if the patient's symptoms were addressed and there were no new complaints at the time of discharge, says Gilman.
"Otherwise, a plaintiff's attorney can say, 'My client was in the ED for five hours. How do you know what his condition was at the time of discharge?'" says Gilman.
- Soni K, Dhaliwal G. Misleading complaint. AHRQ WebM&M [serial online]. July 2012.
For more information, contact:
- Pamela S. Gilman, JD, Barton Gilman, Boston. Phone: (617) 654-8200. E-mail: firstname.lastname@example.org.