Charting This on Transferred Patient Could Deter Lawsuit

If a patient deteriorates because of a transport and later sues, concerns will inevitably arise that the emergency physician (EP) didn’t stabilize the patient prior to transport, or that the patient should not have been transferred, says John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital, also in Cleveland.

EPs needs to clearly document the reasons for the transfer and why the service couldn’t be provided at their hospital, as well as the fact that they did everything possible to stabilize the patient to the best of the capability of the hospital before transfer, advises Tafuri. He recommends these documentation practices:

If the EP could not get into contact with the consultant and as a consequence had to transfer the patient, the EP should include this information in the patient’s chart.

“If stabilization requires a consultant that is at your hospital, that consultant really needs to see the patient prior to transfer,” says Tafuri. “This is frequently not known.”

If a patient with an unstable orthopedic injury such as a knee dislocation is transferred without seeing the on-call orthopedist, for instance, “there are going to be issues,” says Tafuri. “They will want an answer as to why the orthopedist didn’t come in and see the patient.”

• If an unstable patient insists on being transferred, the EP should specify that risks involved with the transfer were explained to the patient and the fact that the patient was advised to stay but refused, and was competent to make the decision.

“Plaintiff attorneys don’t like cases with patients who refuse treatment. It doesn’t play well with the jury,” says Tafuri. “I cannot recall seeing a single case involving an unstable patient who insisted on the transfer, except in a situation where the patient was clearly not mentally competent.”

EPs should ask an ED nurse to advise the patient to stay as well, and document this attempt in the record, advises Tafuri. “If the nurse couldn’t get them to stay either, it’s even more difficult for the plaintiff attorney to argue that they both got it wrong,” he says.

• If the EP is transferring a patient for insurance reasons, the EP should specify that no meaningful deterioration is anticipated during the transfer, that vital signs are stable and not worsening, and that in the EP’s opinion, the patient is stable for transport.

“What you don’t want to see is a patient who could otherwise stay at your hospital, with unstable vital signs, who is very tachycardic or hypertensive, and something happens en route,” Tafuri says.

• If the patient’s vital signs were abnormal at one point in time, the EP should specify that another set of vital signs was taken prior to transfer and they normalized.

“A plaintiff attorney would like to be able to say that the EP last saw the patient at 9:30 and he wasn’t transported until 12:30, and the EP doesn’t know what happened to him during that time,” he says. “Plaintiff attorneys love it when something is overlooked by the physician.”

If the EP checks the patient at 8 a.m., for example, and rechecks the patient prior to deciding on a disposition at 9:30 a.m., the transfer might take several hours to occur. During that time, a nurse might chart abnormal vital signs, or the patient’s report of dizziness or increasing pain. “That minor entry in the record could be very consequential, and look very bad in retrospect,” says Tafuri.

Ideally, the EP should see the patient immediately before transfer and document, “Patient feels well. There are no new complaints.” If the attorney sees that the EP rechecked the patient immediately prior to transfer and determined that the patient was stable, it’s hard for him or her to argue that the patient never should have been transferred because he or she was unstable, explains Tafuri.

• If an unstable patient is being transferred, the EP should acknowledge this and explain why the transfer is necessary.

If a patient is tachycardic, for instance, the EP should record the vital signs and document, “Patient has tachycardia. However, given the risks and benefits, I feel it is prudent to transfer at this time because these services are not available at the hospital.”

“Acknowledge that you know the patient is unstable but that you think the benefits outweigh the risks,” says Tafuri. “Show that you are trying to do what is best for the patient.”