Quality documentation can make all the difference.
If you’ve ever navigated through a lawsuit in Emergency Medicine, you know that the nuances of the case often have nothing to do with the actual quality of care that has been provided. In the past decade, verdicts ranging from $ 125,000 up to $ 2,599,000 were awarded involving cases of “misdiagnosis” of appendicitis in New York.
The scrutiny of the plaintiff’s inquiries is often intensified by a lack of documentation by the emergency clinician. Alternatively, a lawsuit can be successfully defended (or altogether avoided) when the medical provider has included the appropriate detail in their charting. In this arena, quality documentation can make all the difference.
Two Top Pearls
Here are key areas of charting that can enable you to overcome “aggressive” ligation:
1) Your documentation of a disposition re-exam.
2) Your charting of discussion(s) with the primary and / or consulting physician(s).
Clinicians, it’s time to take our charting seriously. Don’t under-estimate the impact quality documentation makes.
Lessons in Humility
Take a look at the following case:
A 12 y/o male is seen for abdominal pain and discharged home. He returns two days later with a ruptured appendix.
At first glance, you might think, what happened in the above encounter? Did the clinician “miss” the diagnosis of appendicitis? True, human error does occur, and we are all human. However, in a number of patient encounters, the root cause often lies elsewhere.
Disease processes evolve over time – regardless of a physician’s clinical ability and excellence in care. This simple fact should not be trivialized or overlooked. If you’ve practiced Emergency Medicine long enough, you’ve seen everyone else’s “bounce backs.” What makes you sure that your colleagues haven’t seen yours?
Have you ever discharged home a patient with appendicitis? Pulmonary embolism? Intussusception? When you care for thousands of patients over a number of years, some of your patients are bound to “bounce back.” In many of these cases, your documentation is the key to detailing the quality of the initial care you provided.
In reviewing the above chart, suppose you find the following documentation:
“Disposition re-exam: The patient appears in no acute distress, mild epigastric tenderness with palpation, abdomen is soft and otherwise non-tender. No McBurney’s point tenderness. No new complaints.”
“I discussed the case with the patient’s pediatrician, Dr. Spencer, and he will follow-up the patient in the office as an outpatient.”
“The patient and mother were counseled about the nature of the medical problem including the differential diagnosis of appendicitis and appropriate follow-up was discussed.”
“The mother was instructed to have the patient return to the Emergency Department if the patient becomes worse, has any problems, or develops new symptoms, including any localization of pain to the right lower quadrant, fever, or vomiting.”
Suppose the Emergency Medicine physician provided the exact same care as outlined above although the documentation was absent. This case instantly becomes open to scrutiny and review.
You might think that such documentation falls under best practices, and therefore would be natural for you and all of the clinicians in your group. That being noted, challenge yourself to take note of the next chart you review. You may be surprised by the omission of such “simple” detail.
Look Out For Your Patients and Yourself:
When our shifts get hectic, charting frequently takes a back seat. Understandably so as the drive is to take care of patients first and charting commonly falls by the wayside. It is precisely during these times, when the emergency department gets busy, that we should pause briefly, allow for that extra 60 seconds (or less), and be complete in our documentation. Never forget, a lack of proper documentation only becomes a problem when the problem (or “bounce back”) arises.
In this setting, an ounce of prevention is certainly worth a pound of cure. With every fall-out encounter, the invitation to scrutiny (and potential litigation) is open. Thus, the onus resides with us, the emergency clinicians, to detail the service we provide. By placing just a small amount of attention towards our charting, hours of retrospective case review can be avoided. More importantly, our patient management is clearly outlined and becomes much easier to defend medico-legally.
Two Key Charting Tips That Will Benefit Your Practice:
1) Document a disposition re-exam. (every chart, every time)
2) Document your discussions with the primary and / or consulting physicians.
Disease processes evolve over time, and sometimes “stuff” just happens. Therefore, strive to ensure your charting details all of your high-quality care. The above two simple actions facilitate excellent patient care, help safeguard your medicolegal risk and enable you to succeed with your finances. After all, one of the best ways to optimize your reimbursement is to ensure that you actually retain it. Your efforts here can make a big difference. Best wishes for success!
- Miller & Zois, LLC; “Appendicitis Misdiagnosis”; millerandzois.com (retrieved 8/30/19)
Great lessons on documentation. There is only one more I would like to add. Once I am done with my chart, I ask my self. Will anyone who reads my chart think I “cared” for this patient as I would for my own son / wife / mom / grandfather? If the answer is no, then I am not done.