Risk Management In Emergency Medicine

by Robin R. Hemphill, NM and Michael R. Williams, MD

• Introduction:
  The concept of risk management revolves around identifying situations that place a provider at risk for complaints, bad outcomes, or law suits. Much of risk management seems to be done in a retrospective manner with physicians and institutions learning from mistakes, rather than trying to identify problems before they arise. This article is designed to identify and explain some basic ideas about how to approach patients in the emergency department, appropriately chart patient interactions, and how to identify high risk situations. Suggestions for good charting are reviewed as are some high risk "chief complaints".
• General Take Home Points:
  When documenting a patient encounter, it is critical to recognize that the chart is a medical document that explains the patient's complaint, exam, treatment, and course. While it might be entertaining and amusing to expound upon the patient's appearance, if it is not relevant to the patient's complaint it should not be included in the medical document. Juries may not find unflattering and mean-spirited comments very pleasant. With this in mind the following types of statement should be avoided:
  A well known, un-shaven, unkempt, foul-smelling, slightly-cyanotic, 62 y/o alcoholic gentleman was carried into our emergency room by three million lice, all screaming, 'Please save our host'."
  -excerpt from the doctor's written note shown to the jury in a medical malpractice suit, circa 1977.
• Other Important Points:
  
  • Develop the foresight to know which charts require the most attention. Do this by becoming familiar with and learning to anticipate the "High Risk" situations and complaints that require better documentation than routine cases.
  • Recorded diagnosis must be substantiated by the "body" of the chart. From a medical-legal standpoint, we are not required to make the correct diagnosis 100% of the time, but the chart must reflect that a logical diagnostic process was utilized to arrive at the diagnosis that appears on the chart. Do not use diagnoses that the chart does not support. Perhaps, if the physician had read over his own chart in the case below, he would have noted that the examination did not fit well with his diagnosis.
    • Diagnosis substantiated ?
      1. 1 1 Y/o male, CC: scrotal pain & swelling, abdominal pain, vomiting.
      2. VS: BP 118n2, P 1209 R 20@ T 98.8
      3. PE: Alert, rriild-mod distress. ABD: Soft, BS hypoactive, nontender.
      4. Rectal:NT, stool heme negative.
      5. GU: Right hemiscrotal swelling and tenderness.
      6. DX: Gastroenteritis
      7. Disposition: Home
      8. Outcome: The parents and family retumed to Peds clinic 12 hours
    • The child's pain had decreased, but the examination remained as above. An urgent Urology consult was obtained and the child was taken to the operating room. OR findings: Non-salvageable right testicle.
  • The chart "body" must explain the patient's clinical course throughout the ED visit. Many patients receive therapy in the ED and their response to therapy will determine the disposition, the response (or lack of response) must be documented so that the reason for the disposition can be identified on retrospective review of the record. The response can be as simple as "pain relief noted with Torodol", or as complex as the improvement of a septic patient with therapy. Also helpful is documentation of repeat examinations showing a progression of improvement in the patient's symptoms. This is particularly true of complicated patients that are allowed to go home.
  • Disposition must be congruent with the recorded diagnosis. A logical treatment plan must be initiated based upon a diagnosis. Do not send a patient home with a diagnosis that warrants admission. Sending a patient home from the ED with the charted diagnosis of "Rule-out MI" or "Unstable angina" makes very little sense. On the other hand, admitting a patient with "Uncomplicated Urinary Tract Infection" also makes little sense and may not be reimbursed.
  • If it wasn't charted, it didn't happen. The legal system may indeed successfully argue in a court of law that if something important was not charted, then it did not happen. It is not possible to document everything, but procedures and specific bits of information given to the patient need to be recorded on the chart.
  • Patient care is more important than charting but... the chart will become important to you when notice is received that a patient t seen in the ED had a bad outcome or has filed a medical malpractice claim. Excellent charting will not undo poor medical care or poor physician-patient interactions. After the billing and follow-up has taken place, one of the key purposes of the medical record is to protect those that participate in a patient's care.
• Purpose of the ED Record:
  • Provides information to other health care providers. This fact is important for patients being admitted to the hospital since in many institutions the patient may not be seen again for several hours later. The inpatient physician can get a clear picture of what the complaint was and what therapy was offered. It also allows a chance to detect anything else that may need to be addressed (That small pulmonary nodule that was seen on CXR, but had little relevance to the main problem) of the care that the patient received in the ED. For patients that are discharged a well documented chart makes clear what the plan was for the patient and what the thought process in making a disposition.
  • Source of information for QA monitoring and retrospective research. Chart information that is collected over time provides data that may be used to improve services, solve systems problems,determine staffing and subspecialty needs of an ED, and increases the body of knowledge in our specialty.
  • Basis for hospital and professional services fees. A well documented chart is typically able to bill for more than a chart with a paucity of information.
  • Helps to protect the legal interests of the patient, the hospital, and medical professionals. Beyond the first 2-3 weeks after the patient's ED visit, this is the main purpose of the medical record. A chart with a wealth of information shows care and concern, and will also help the provider to remember the patient later when problems arise.
• Why Is a Good ED Record Important to You?
  Ultimately, most physicians want to provide excellent care for all patients. Therefore, even if lawsuits never occurred and all patients got better, there would still be many reasons to document charts well.
  
  • Improves care to your patients during the actual visit. - serves as a thought organizer & memory jogger. (e.g. your pen becomes "trained" to write lino meningismus" on all febrile patients so you remember to go back and check for meningeal signs on that febrile child that you are about to discharge.)
  • Helps you and your colleagues see "bounce-backs" and rechecks. A good chart from the previous visit explains how the initial diagnosis was formulated, the results of tests performed during the initial visit, and the patient discharge instructions.
  • Complaints against you or your department can be addressed more effectively. If patient dissatisfaction is perceived by you or another member of the health care team and does not appear to have been resolved prior to the patient's departure, then noting pertinent facts on the record at the time they occurred will facilitate future investigation if a formal complaint arises.
• The Actual Charting Process - a recommended method:
  Record time that the patient is seen. You may not accurately remember this later so do it at the onset of the evaluation. Recorded times become important in certain cases with bad outcomes if timely intervention might have prevented the bad outcome (e.g. use of thrombolytics in acute MI). This also helps address patient complaints about the waiting times. Often, the patient waited less time than they thought.
  
  • Physician Signature. Unless you're the only physician working in the department, other health care providers need to know who is taking care of a particular patient, who is ordering the meds, etc. Signing the chart does not mean that you are finished caring for the patient or finished with the charting so don't be afraid to do this at the beginning of an evaluation.
  • Scan top portion (clerical data & nursing notes), taking particular note of the patient's age, chief complaint, vital signs, & past medical history (if recorded). If some clerical data was left blank this is the time to fill it in.
  • Verify the chief complaint. Cut to the chase inunediately - (you don't want to pursue the complaint of abdominal pain that was given to the triage nurse if the patient's real complaint is penile discharge).
  • Record orders for procedures & medications within the time frame dictated by the patient's presentation. For "sick" patients, the orders for procedures & meds will many times be given verbally prior to generating the chart. (Otherwise the patient could die waiting for the chart to be generated by clerical personnel.) Resuscitation sheets are used in critical cases so that a designated recorder can chart the minute-by-nfinute account of the patient's course as the patient undergoes various procedures.
  • Complete the body of the chart with adequate data to support the diagnostic impression. This will include the history, physical exam, differential diagnosis, and the results of diagnostic tests, consults, and treatments. Anyone should be able to read this portion of the chart at a later date and figure out what happened to the patient while in the ED. Do not depend on nursing notes to do this. Those patients that require one or more re-evaluations prior to disposition, an "ED Course" note should be written by the physician to explain why a particular disposition was chosen. To only record an initial exam would be inadequate for any condition that changes over the course of the ED visit. Also, any erroneous data in the clerical or nursing note portion must be clarified or corrected in the physician's history section.
  • Final Diagnostic Impression recorded at time of disposition. This should represent the most reasonable diagnosis at this point in time. Some disease processes may not have sufficiently declared themselves in order for us to make a precise diagnosis. A good example is "Abdominal Pain, Uncertain Etiology". The disposition of the patient should be congruent with this diagnostic impression.
  • Record appropriate discharge instructions. The discharge instructions should be appropriate and complete for that particular diagnosis and disposition.
  • Does the chart body explain the course through the ED ?
    1. Time seen: 0830 VS: P 160, R 40. RA 89%
    2. Hx: 5 y/o male with asthma, brought by parents, c/o SOB X 8 hours. +prior ETT.
    3. Exam: Mod. resp. distress. +Retractions.
    4. BS = B, poor air movement. PF <60
    5. Orders: Albuterol nebs Q 30 min X 3.
    6. Disposition: Home with parents at 1130.
  • While it may have been appropriate to send this child home if he improved markedly, there is nothing in this record to suggest that this patient changed from his initial presentation.
• Miscellaneous Do's and Don'ts
  
  • Read and acknowledge the nurses'notes. Discrepancies between physician and nursing observations must be addressed while the patient is still in the department and the chart must reflect a resolution of that discrepancy. In some cases it is helpful to go back to the nurse who got a history different from yours to address the discrepancy and to determine why it occurred. 2. Abnormal vital signs must be explained.
  • Ignoring nursing notes
    1. 56 y/o male, CC: malaise, fever. T 103.9
    2. Nursing Note: (on separate page) "Hx of rectal pain X 2 days." (This hx not verbally offered to the physician by the patient or the nurse.)
    3. PE: Nontoxic appearing. Nonfocal for fever source.
    4. LABS and CXR: unremarkable except for WBC 16,000.
    5. ED progress: "After 2L IVF, patient feels well enough to go home."
    6. DX: Viral Syndrome
    7. Disposition: Home. Return to ED p.r.n.
    8. Outcome: Returned 24 H with sepsis secondary to perirectal abscess.
  • Do not give anyone cause to view the record as anything but truthful. (E.g. don't write CN II-XII intact in an infant- "Doctor, how did you test CN V, VIIII, and IX in this patient?")
  • Do not use terminology that demeans the patient. The abbreviation: "SPOS" was written in the nursing note of a plaintiff s chart that appeared before a jury in a malpractice claim. At trial, when the plaintiff s attorney asked the nurse the meaning of"SPOS", she responded by saying it stood for "Subhuman Piece Of Stool."
  • Lack of space is not an excuse for inadequate documentation.
  • Correct errors with a single line, initial, date, time. Obscuring an error gives the appearance that some damaging information was hidden.
  • Present information in such a manner that any other reasonable physician, judge, jury, or attorney can come to the same diagnostic and therapeutic decisions.
  • Adding an addendum to the chart at a later date is controversial. If it is felt to be necessary, date and time the late entry.
• Conclusion:
  You can't write up or dictate every chart to perfection in a busy ED without neglecting patient care. The key to defensible charting is to develop the foresight to know in advance which charts require the most attention. Defensible charting practices will not guarantee that you won't be sued, but many times a thorough, well documented chart will act as a deterrent and a plaintiff s attorney will be less eager to accept a case than if the charting appears incomplete or illogical.
• References:
  1. Rogers, John T., MD Risk Management in Emergency Medicine. Emergency Medicine Foundation - American College of Emergency Physicians, Dallas, 1985.
  2. George, James E., MD, JD Law and Emergency Care. St. Louis, Toronto, London: C.V. Mosby Co., 1980.
  3. Emergency Physician Legal Bulletin (EPLB). Med/Law Publishers. Westville, New Jersey. Quarterly.
  4. Henry, Gregory L., MD Emergency Medicine Risk Management. American College of Emergency Physicians, Dallas, 1991.
  5. Flick, Gervase M., MD, JD Medical Malpractice, Handling Emergency Medicine Cases. Shepard's/McGraw-Hill, Inc., Colorado Springs, 1991.

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