Disagreements are as common as patients with back pain and just as challenging.
One of the most frequent calls I get from providers is about how to document disagreements. Disagreements are inevitable and always need to be handled delicately. This article will give some suggestions on how to have CYA documentation that shines with civility and keeps you out of an attorney’s clutches.
Us vs. Them
- Case 1: A 50-year-old diabetic has a painful cellulitis with a temp of 101.3 and a heart rate of 105 after fluids. You think he needs admission, but the hospitalist disagrees.
Hopefully your hospital has a policy that if there is an unresolvable conflict about whether the patient requires admission or not, the consultant discharges the patient. If so, the chart should reflect that you called the hospitalist for admission and the reasons why the patient needs admission. Avoid saying “the patient looks too ill to go home” or similar. Simply state: “The patient looks ill and is tachycardic with decreasing blood pressures, admission requested for IV fluids and antibiotics, Dr. Hospitalist here evaluating patient.”
It becomes much trickier if you must discharge a patient that you believe needs admission. Restate the previous quote, but then conclude “Dr. Hospitalist has evaluated the patient and does not feel admission is warranted, please see his note for details. Patient is tolerating POs and has ability to return to the ED if needed and agrees with hospitalist’s discharge plan. Dr. H has asked me to discharge the patient home. I have asked the patient to return for reevaluation immediately if…..” It is essential that you not rant about how ill-advised it is for the hospitalist to send the patient home because you are obliged to advocate for the patient. If you strongly believe that the patient requires admission, you need to notify your departmental chief or the CMO that this is an unsafe patient discharge. If you are not strongly enough against the discharge to call your CMO, then don’t hang yourself by saying that you totally disagree with the discharge. When you write the discharge order, you are going to be held responsible for it.
- The consultant will not come in until certain tests are done—again, you are the only one on scene so you bear the brunt of the responsibility. If you feel the consult is emergent, you must tell the consultant so and move up the hierarchy if the consultant does not comply. If you feel the consult should come now, but you aren’t ready to call your chief/CMO, then say “Dr. Surgery was called to see patient, but would like CT scan first. Informed that patient has an acute abdomen with a BP of 100/55 and HR of 115. Surgery would like antibiotics and CT prior to surgical evaluation.” Then keep a close eye on the patient and make any additional phone calls as they are needed if the patient condition changes.
When nurses are not your friends
- Too often there is a smoking gun in medical records in the form of nursing notes. Nurses may inadvertently document things that are misleading or just not accurate, or they may be engaged in their own chart war with you. Making matters worse, nursing notes can be very difficult to find in many electronic health records. Here are some suggestions on how to address dangerous nursing documentation.
- Case 1: The nursing note describes a child as “lethargic” or “having a blistering rash” or “in respiratory distress,” but you disagree. If you have a RN that is approachable, then it could be easy to explain the importance of applying these words to only specific clinical situations. For some nurses, however, this will be seen as a power struggle or a criticism of their work. Evaluate how the RN will respond, and don’t take aside an unreceptive RN to explain the difference between a purpuric vs. blistering rash, because the emotional message will overwhelm the factual. Ask your charge RN for help—show her the nursing note and take her to the patient’s room to evaluate the patient. Share with her how some words are buzz words. Discuss if the note needs to be changed or if another note can simply be added (“upon reevaluation, rash is papular rather than blistering” or “child is using accessory muscles, but is not in respiratory distress”) Review the new note after it is written to make sure that it does not say “physician requested that I addend my note to say that the child is not lethargic.” Lastly, be open to being incorrect in your assessment—perhaps the child does have meningitis and nursing has saved you and the child!
- Case 2: “Patient with low blood pressure—MD notified.” Nurses are rarely named in malpractice suits, but their notes are always scoured to look for evidence of your negligence. In numerous cases there is repeated documentation by the nurse of abnormalities in vital signs or patient condition with the catchall phrase “MD notified.” Since this is never qualified, it could be that they approached you, waited until you were off the phone and told you in a grave voice that the patient’s blood pressure is tanking, or it could be that you are signing an ECG while you head into another patient’s room and the nurse shouts something from her computer about the blood pressure in room 8. Your response should be as simple and factual as “RN documentation noted, but was not aware of low BP until entering room at 8 p.m., fluid ordered immediately.” This is the best way to handle nursing documentation that is contrary to your belief in any way. “RN noted chest pain in triage note but patient denies chest pain on H and P.” If it’s an important area of disagreement, take the RN into the room and query the patient together and document that upon re-questioning the patient is denying chest pain to both MD and RN. This is very important, for example, if someone has written that a psychiatric patient is suicidal when the patient is being discharged home because they denied suicidality to you and the behavioral health specialist.
“Can I have copy of my ER visit?”
Long ago I attended a lecture at ACEP and heard Greg Henry preach about writing the word “obese” in the medical record. Knowing Greg, I suspect that he had many more colorful words besides that one, but his point was this: When your medical records are read by a patient or to a jury, does a bias come out that makes you look bad? He advised referring to the BMI rather than calling a patient “obese” because it is a charged word.
Here are some other charged words in charts with some suggestions of how to rephrase so that the same information is conveyed, but using medical terms so that it sounds less judgmental.
- “The patient is rambling historian”—consider “clear history unable to be obtained as patient is tangential.” If true, you can add “and is unable to be redirected.”
- “The patient refuses to walk” —neurologic symptoms that appear to not be real need careful notation of facts only. “Patient states he is unable to walk, but is noted to use his legs to push himself up in bed,” “Patient has give-away strength in his legs,” “Patient says that he cannot speak, but is able to mouth words and write on paper,” “Patient says that she cannot use her hands, but is seen dialing her phone and unbuttoning her shirt.”
- “The patient is seeking narcotics” was put in a medical record of a person who turned out to be septic. In case this outcome happens to one of your patients say “The patient is repeatedly asking for dilaudid, and is refusing non-narcotic analgesia and ice pack. “
It is common for patients to request a copy of their ED visit so steer clear of using language that could be interpreted as offensive. A year was wasted by a physician in a lawsuit when a transgender individual was referred to as her birth pronoun rather than as “he.” Respect for our patients must be conveyed not only in person, but in the documentation of our encounters with them.
Lastly, after reading their records, some patients want the doctor to change what is said in their ED note. While some are frivolous, some are meaningful—here is such an example:
“The x-ray report says that I have a curvature of my spine suggestive of possible scoliosis with clinical correlation suggested, the ED doctor wrote scoliosis as my discharge diagnosis, and now I can’t get disability insurance because they say I have scoliosis.”
- Analysis: Sometimes less is more, as our documentation carries weight. I have seen ED doctors discharge patients with “COPD” simply because the patient was wheezing, without any imaging or PFTs to back up the diagnosis. Even if that is the likely diagnosis in a 70-year-old with a 100 pack year smoking history, ICD-10 does not recognize “likely or possibly,” so one is better off using “Wheezing” or “reactive airway disease” to describe what you are finding. If you have trouble finding the correct discharge diagnosis, you can make a quick note saying “diagnosis bronchospasm, unable to find correct code in EHR.”
Hopefully this will help you navigate the difficult waters of disagreements in the ED so that you avoid getting caught in the rip tide of a chart war. Malpractice attorneys love using your own words against you. Don’t let them! A carefully documented medical record is a gift to your future self.
Avoid Chart Wars by Learning to READ:
- Respect the patient in your documentation.
- Eliminate hot button words or words that suggest bias.
- Advocate for your patients by going up the hierarchy when you disagreement with consultants, otherwise simply describe the disagreement factually and without emotion.
- Document respectfully.