Articles Tagged With: history
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Legal Exposure Regarding Recurrent Low-Risk Chest Pain
The most important actions an emergency physician can take are to gather a thorough medical history and correctly interpret the ECG.
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Incomplete Medication Lists Can Lead to Allegations of Negligence
Just 23% of older adults in the ED gave a medication list that mirrored pharmacy records, according to the results of an analysis. More than half the patients omitted antibiotics they were taking at the time of the visit. Not knowing about a medicine can lead to dangerous therapy or misdiagnosis.
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Many Charts Lack Any Evidence of Thorough H&P
Often, a portion of the history, assessment, or evaluation was handled, but for whatever reason does not make it into the emergency medicine record. This makes it appear as though a poor or incomplete assessment was conducted. Double check these items to see they are included.
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Preoperative Assessments Can Be Weak Point, Increase Liability Risks
Preoperative assessments are critical to patient safety and reducing liability risks. Some assessments are inadequate and fail to identify risks that could be avoided.
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Any Discrepancy in ED Chart Hurts All Med/Mal Defendants
With multiple providers documenting in the ED medical record, there are bound to be some discrepancies from time to time. However, the chart must reflect that discrepancies were recognized and considered by the ED provider.
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Sparsely Charted History and Physical Complicates Med/Mal Defense
The chart should clearly show what was considered, and what was ruled out, during the visit. Thoroughness in this regard leads the EP to the appropriate testing, treatment, and disposition.