After a patient complained of knee problems and the triage nurse recorded a chief complaint of knee pain, the emergency physician diagnosed a musculoskeletal injury. Just before discharging the patient, however, the physician noted the patient appeared unsteady and ultimately diagnosed a subdural hematoma.1
If the chart showed that the physician had done a thorough assessment and found no indication of neurological causes for the patient's knee pain, this documentation of this information would have been legally protective for the physician, if the patient had returned with an subdural hematoma days later, according to Krishan Soni, MD, MBA, chief fellow in the Division of Cardiology at University of California, San Francisco.
Physicians need to understand that patients often give inaccurate information, whether intentionally or not, Soni underscores. "This is an important problem we face in medicine, and physicians need to take deliberate steps to countermand that," he says.
Some patients might knowingly alter their complaint to be seen more quickly. "A small number of patients may use certain buzzwords or change their story with that in mind," says Soni.
Patients don't always realize which pieces of their history are important. "Patients may have many symptoms and pick one to report which might not be the most medically relevant, causing providers to go down the wrong track," says Soni.
Patients might inadvertently use misleading terms to describe symptoms. "For example, Asian patients use the word 'dizziness' to describe a whole panoply of symptoms. To them, it may mean they are tired or lack energy," Soni says.
He gives these strategies to avoid malpractice suits related to inaccurate or misleading information given by patients:
. Always independently ask patients why they came in.
Most patients already have told a nurse their symptoms before the physician sees them. The nursing history "is often the 'launching off' point for the evaluation," says Soni. "But if you focus just on that piece of information, you are likely to miss out."
. Don't focus solely on the patient's specific complaint.
Soni recommends physicians ask themselves, "What is the worst thing that could be happening to this patient?" Document that other etiologies for the patient's complaints were at least considered.
Patients often don't reveal concerns
Aware of how busy their doctors are, many patients feel hesitant to raise concerns that seem trivial, says Sue Larsen, president of Astute Doctor Education, a New York City-based firm specializing in improving physicians' ability to communicate with patients. Others don't want to be judged negatively by their doctor or feel their doctor isn't interested.2
"Up to 45% of patient concerns are never raised or discussed," says Larsen.3 "This can lead to missed or delayed diagnosis, accompanied by an increased risk of medical malpractice litigation." She suggests these approaches to reduce risks:
. Give patients the opportunity to discuss their concerns fully before moving on to the treatment stage.
"This can reveal important information that may affect the diagnosis and treatment choices," says Larsen.
. Always ask "What else would you like to discuss?" before moving on to the diagnostic phase.
"Patients often don't tell you important information and concerns in the first instance," says Larsen. "Sometimes they need a little persuasion."
- Soni K, Dhaliwal G. Misleading complaint. AHRQ WebM&M [serial online]. July 2012.
- Cape J, McCulloch Y. Patients' reasons for not presenting emotional problems in general practice consultations. Br J Gen Pract 1999; 49(448):875-879.
- Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152(9):1,423-1,433.
- Sue Larsen, President, Astute Doctor Education, New York, NY. Phone: (646) 783-1000. Email: suelarsen@
- Krishan Soni, MD, MBA, Chief Fellow, Division of Cardiology, Department of Medicine, University of California, San Francisco. Email: krishan.soni@