Chart Discrepancies: Basis for Legal Claims
Unaddressed discrepancies damaging
According to the nursing notes, a 15-year-old boy presented to the ED with headache, neck pain, nausea, and vomiting. "The emergency physician (EP) used a template for abdominal pain and crossed off the neurology section, including headache, in the review of systems," says Ken Zafren, MD, FAAEM, FACEP, FAWM, who reviewed the case. Zafren is EMS medical director for the state of Alaska and clinical associate professor in the Division of Emergency Medicine at Stanford (CA) University Medical Center.
The patient was discharged from the ED with a diagnosis of gastroenteritis, and died at home a few days later from a ruptured arteriovenous malformation (AVM). This had been diagnosed as an apparent incidental finding on a CT scan done to rule out a soft-tissue mass of the neck a few days before he presented to the ED. The case was settled.
"Even without the history of the AVM, the patient’s symptoms as described by the nursing notes should have mandated a CT and a lumbar puncture if the CT did not show bleeding," says Zafren.
Do the ED nursing notes mention an abdominal patient’s "guarding and rebound," but the EP’s documentation makes no mention of it? If the patient is later found to have an acute abdomen and a malpractice suit is filed, "the plaintiff attorney will allege the nurse had it right and the doctor didn’t," says John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland.
Inconsistencies in the chart often serve as the basis for a legal claim against EPs, says Tafuri, such as abnormal pulse oximetry or blood pressure that is not addressed at the time of discharge or admission.
There will always be discrepancies in charts, but it’s the unaddressed discrepancy that is damaging to EPs in the event of a lawsuit, warns Kevin Klauer, DO, EJD, chief medical officer at Canton, OH-based Emergency Medicine Physicians.
"It’s not that the other provider is always wrong," he says. It may be that the patient told a nurse that the current headache is the worst of his life, but omitted the fact that he’s had the same "worst" headache every month for years.
"If a different provider gets a different answer, the EP can say, I’m the primary provider, when I talked to the patient, this is what they said, and this is the right answer,’" Klauer says.
Other providers sometimes get different information from the patient than the EP, even if they ask the very same questions. "I’ve had experienced providers say, I asked them that question and they said no,’" says Klauer. "Well, maybe you gave the patient a chance to think about it." Patients also don’t know what pieces of information are critical, such as chest pain that radiates to the left arm.
Klauer has reviewed claims where EPs defended themselves by claiming a nurse didn’t give them important information.
"That is a golden gift to the plaintiff attorney," says Klauer. "Because when you point fingers and say you would have done something differently, what you are saying is someone is negligent — we are just deciding who."
Flag Abnormal Vitals
The electronic medical record (EMR) at Fairview Hospital’s ED flags abnormal vital signs charted by nurses so these are easily visible by EPs. In addition, if EPs are discharging a patient with abnormal vital signs, the EMR alerts the EP.
"It doesn’t stop you from discharging the patient, but it calls your attention to it," says Tafuri. "The EP can then determine if it is something that is critical to address, or something they want to comment on in the chart."
In some cases, EPs decided to admit the patient after being alerted to abnormal vital signs that they’d overlooked, such as a patient who is persistently tachycardic without explanation and ultimately diagnosed with pulmonary embolus.
Patients with abnormal vital signs at the time of discharge are more likely to have bad outcomes than patients discharged without abnormal vital signs, adds Tafuri.
In some cases, the EP still discharges the patient but is able to acknowledge the patient’s abnormal vital signs in the chart. "If relevant, the EP writes a note explaining that they saw the nursing notes, and why they feel it’s O.K. for the patient to go home," Tafuri. "Should there be a legal issue down the road, you are in a far better position if you acknowledge the nurse’s notes."
Notes Can Help or Hurt EP
Nursing notes have the potential to help or harm EPs in malpractice litigation, says Zafren. Zafren is currently reviewing a claim involving a patient with frostbite who arrived in the ED early in the morning and who was not seen by the EP on duty at that time.
The frostbite was allowed to thaw spontaneously rather than receiving the correct treatment, which would have been rapid thawing in warm water, resulting in increased tissue damage.
There was one EP’s name on the patient’s record, but care was given by a different EP. "The nursing notes and metadata make it clear that the patient was seen only by a second emergency physician after change of shift," says Zafren. "This was confusing until I reviewed the nursing notes."
Zafren recommends these practices involving nursing notes to reduce liability risks:
• Read nursing notes during the patient visit and just before discharge.
"I make sure I am not missing something important that the nurses didn’t tell me or, more likely, that they did tell me but I failed to pay sufficient attention," Zafren says.
• Don’t sign the note until after the patient has left the ED.
This allows Zafren to review the nursing notes once more so no late entries are missed. "EPs should never lose sight of the fact that they would be nothing without the nurses," says Zafren. "Nurses have bailed out every practicing EP many times by calling their attention to things they might otherwise have missed."
• Never criticize nursing notes in the patient’s chart.
"It always looks terrible when one health care provider criticizes another in the medical record," says Zafren.
Zafren says that while EPs are viewed favorably by juries, he believes that ED nurses are viewed even more favorably. Thus, an EP who criticizes a nurse would be viewed very unfavorably.
"I learned long ago to write on nursing notes appreciate nursing notes’ to show that I had read them," says Zafren. "The EMR version of this is a check box that says nursing notes reviewed.’"
For more information, contact:
• Kevin Klauer, DO, EJD, Chief Medical Officer, Emergency Medicine Physicians, Canton, OH. E-mail: email@example.com.
• John Tafuri, MD, FAAEM, Regional Director, TeamHealth Cleveland (OH) Clinic. Phone: (216) 476-7312. E-mail: firstname.lastname@example.org.
• Ken Zafren, MD, FAAEM, FACEP, FAWM, Alaska Native Medical Center, Anchorage, AK. Phone: (907) 346-2333. E-mail: email@example.com.