Some Charting Methods Put Sued EPs in a Tough Spot

Consider your defense

What an emergency physician (EP) documents can unquestionably influence the outcome of a lawsuit, but is the same true for an ED's charting method?

"I have come up against this issue a lot. I think short, standardized forms can be very tough to defend from," says Michael Blaivas, MD, RDMS, professor of emergency medicine in the Department of Emergency Medicine at Northside Hospital Forsyth in Cumming, GA.

Blaivas has seen multiple lawsuits in which the triage nurse initially used a standardized form for abdominal pain or nausea/vomiting, and the patient was later found to have a myocardial infarction after a lengthy ED stay or post-discharge.

"It is always painted by the plaintiff's council that the physician was off base from the beginning," he says. "If you have changed direction in the case, the documentation simply does not allow for it."

While EPs using standardized forms are able to claim something was negative simply because it wasn't checked, a dictation leaves little room for doubt as to whether something was done. However, if something isn't covered, such as an extremity examination, it's harder for the EP to argue that in fact it was done and normal.

"In all honesty, standardized forms seem to help sub-par physicians and hurt those who are above par," he says. Electronic standardized forms may create problems if a dictated portion isn't available until sometime after the patient's initial ED visit, or before test results are back, adds Blaivas.

"However, I have never seen anyone not be able to argue that it takes time for someone to transcribe the report and it was not available yet, and so the EP went by the patient's history," says Blaivas.

The EP can explain that the decision to send a patient home was reasonable at the time of the dictation, for instance, and the corrected and now elevated D-dimer results were not yet available.

Blame Documentation?

Blaivas says that that careful and thorough documentation is hardest for a plaintiff's attorney to attack, but this can't be achieved for complicated cases using a short, standardized form. Any template that does not allow the jury to follow the train of thought of the physician, or the time-line in the ED, raises questions that the plaintiff can exploit, he explains.

On the other hand, Blaivas has seen cases defended involving standardized forms that weren't completely filled out by EPs, which indicated almost nothing about what occurred or the decisions made.

In these cases, the EPs simply blamed the documentation for not having enough space to fill in information or being too inflexible. "Surprisingly, it can work," says Blaivas. "Some of the toughest ones to follow can be electronic templates, especially since they sometimes sneak in descriptions that are clearly inconsistent with what the physician or nurse noted elsewhere."

EPs should think about where templates have shortcomings, advises Blaivas. "It is always tempting to just document enough to get paid, and not waste too much time on the simple case," he says. "However, it could be the one that gets you sued."


For more information, contact:

• Michael Blaivas, MD, RDMS, Professor of Emergency Medicine, Department of Emergency Medicine, Northside Hospital Forsyth, Cumming, GA. Phone: (302) 832-9054. Fax: (302) 832-0809. E-mail: