Appropriate documentation

[theseeker4]

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So I had a patient last night that I sent home without workup but is semi-high risk due to being a homeless psych patient. Patient was a woman who had a history of homelessness, some type of psychotic diagnosis with prior visits for behavioral health, and came in by ambulance because she wanted to rest. When I tried to evaluate her she refused to cooperate, refused to explain what complaints she had, she pushed a can of soup in my hand and told me to heat it up for her, would just shove her bag of meds into my hand when I asked for her medical problems, and said she was homeless and hungry when I asked her why she was there. She also insisted that I call her care worker at 3:00 am so she would go pick up "her check" for her so she could get her money, and kept demanding that I and the nurses give her money, because she wanted it. She never made a threat, did not appear to be responding to internal stimuli, and her vital signs were stone-cold normal. Denied SI/HI. She refused physical exam other than the most superficial examination. After several attempts to get something, anything regarding a medical complaint out of her, with her just arguing with me about having to give her money, call for her check, and warm up her soup, I talked to my attending and we decided to just DC her.

My question is about documentation. I was as thorough as I could be documenting her mental status, that she was uncooperative but no evidence of florid psychosis, that she was A+O x 4, ambulating well, no evidence of intoxication, able to answer questions appropriately but refusing to cooperate with most questions, documented normal vital signs, refused exam, etc. I was just wondering what others do in these cases to try to protect themselves as much as possible so they don't get sued if the patient drops dead tomorrow, or kills herself, or got hit by a car, etc.

 

[miacomet]

Not your problem, but your attending's. Enjoy residency while you can.

 

[theseeker4]

Not your problem, but your attending's. Enjoy residency while you can.

LOL, very true, but I would like to learn how to handle it before it is my problem.

 

[miacomet]

LOL, very true, but I would like to learn how to handle it before it is my problem.

Worry about the medicine, not about getting sued. That's for later.

 

[Psai]

A&Ox3, following commands, mentating appropriately. Performed screening medical history and exam, patient without acute medical emergency or complaint. Discharge to home.

 

[RustedFox]

Psai has it right.

 

[WilcoWorld]

Include patient quotes in your HPI.
Make sure the RN's documentation accords with yours.
Explicitly chart absence of SI/HI/psychosis and the refusal of evaluation.
Invite the patient to return if she wants an evaluation.
Move on.

 

[Groove]

1) Malingering (ICD10 Z76.5)
2) Homeless (ICD10 Z59.0)
3) Left against medical advice (My EMR lets me code this but I'm not sure it has a definite ICD10 code...)

A&O x 3, no psychosis, no SI or HI. VSS, NAD. The pt refused all care and requested to leave. I explained risks in leaving including missed diagnosis resulting in death or permanent disability. The pt confirmed understanding, demonstrated medical decision making capacity and elected to leave against medical advice.

Honestly though, if there is no chief complaint and nothing worrisome on the MSE, I wouldn't particularly feel the need to cover myself but that's my standard blurb for the AMA types.

 

[Apollyon]

Psai has it right.

... Said no one ever (except you).

 

[TooMuchResearch]

This is a common presentation. You just document the stuff you mentioned. Where is the risk? You have a patient who came in of her own volition, with no medical concerns, asking for food, sleep, money, and to have you make a phone call. Just document that, discharge, and move on with your day.

 

[TooMuchResearch]

Also, she didn't refuse an exam. You had no reason to lay hands on her anyway. If you don't have a from the door / hands off exam, write one now.

 

[hamstergang]

I was just wondering what others do in these cases to try to protect themselves as much as possible so they don't get sued if the patient drops dead tomorrow, or kills herself, or got hit by a car, etc.

Who would sue you in this case?

 

[filhodeinferno]

So I had a patient last night that I sent home without workup but is semi-high risk due to being a homeless psych patient. Patient was a woman who had a history of homelessness, some type of psychotic diagnosis with prior visits for behavioral health, and came in by ambulance because she wanted to rest. When I tried to evaluate her she refused to cooperate, refused to explain what complaints she had, she pushed a can of soup in my hand and told me to heat it up for her, would just shove her bag of meds into my hand when I asked for her medical problems, and said she was homeless and hungry when I asked her why she was there. She also insisted that I call her care worker at 3:00 am so she would go pick up "her check" for her so she could get her money, and kept demanding that I and the nurses give her money, because she wanted it. She never made a threat, did not appear to be responding to internal stimuli, and her vital signs were stone-cold normal. Denied SI/HI. She refused physical exam other than the most superficial examination. After several attempts to get something, anything regarding a medical complaint out of her, with her just arguing with me about having to give her money, call for her check, and warm up her soup, I talked to my attending and we decided to just DC her.

My question is about documentation. I was as thorough as I could be documenting her mental status, that she was uncooperative but no evidence of florid psychosis, that she was A+O x 4, ambulating well, no evidence of intoxication, able to answer questions appropriately but refusing to cooperate with most questions, documented normal vital signs, refused exam, etc. I was just wondering what others do in these cases to try to protect themselves as much as possible so they don't get sued if the patient drops dead tomorrow, or kills herself, or got hit by a car, etc.

The

So I had a patient last night that I sent home without workup but is semi-high risk due to being a homeless psych patient. Patient was a woman who had a history of homelessness, some type of psychotic diagnosis with prior visits for behavioral health, and came in by ambulance because she wanted to rest. When I tried to evaluate her she refused to cooperate, refused to explain what complaints she had, she pushed a can of soup in my hand and told me to heat it up for her, would just shove her bag of meds into my hand when I asked for her medical problems, and said she was homeless and hungry when I asked her why she was there. She also insisted that I call her care worker at 3:00 am so she would go pick up "her check" for her so she could get her money, and kept demanding that I and the nurses give her money, because she wanted it. She never made a threat, did not appear to be responding to internal stimuli, and her vital signs were stone-cold normal. Denied SI/HI. She refused physical exam other than the most superficial examination. After several attempts to get something, anything regarding a medical complaint out of her, with her just arguing with me about having to give her money, call for her check, and warm up her soup, I talked to my attending and we decided to just DC her.

My question is about documentation. I was as thorough as I could be documenting her mental status, that she was uncooperative but no evidence of florid psychosis, that she was A+O x 4, ambulating well, no evidence of intoxication, able to answer questions appropriately but refusing to cooperate with most questions, documented normal vital signs, refused exam, etc. I was just wondering what others do in these cases to try to protect themselves as much as possible so they don't get sued if the patient drops dead tomorrow, or kills herself, or got hit by a car, etc.

Do what you did and don't worry because that patient doesn't have the wherewithal to ever sue you. Her family probably doesn't, either.

 

[TooMuchResearch]

The


Do what you did and don't worry because that patient doesn't have the wherewithal to ever sue you. Her family probably doesn't, either.

But again, sued for what? Not providing enough sandwiches? Not heating her soup? Not making a non-emergent phone call she can also make on her own? Not letting her sleep in the ED?

 

[theseeker4]

But again, sued for what? Not providing enough sandwiches? Not heating her soup? Not making a non-emergent phone call she can also make on her own? Not letting her sleep in the ED?

My concern was more that she wasn't cooperative, and therefore I couldn't necessarily get a well-documented assessment to demonstrate she wasn't psychotic/etc. That is all I was wondering whether I had sufficient documentation to demonstrate that.

And regarding who would sue, there is always some relative who couldn't be bothered to care that their family member is living on the street and has no where to go, but willing to come out of the woodwork at the first hint that there is a payday to be had in the form of a lawsuit.

 

[GeneralVeers]

Don't be overly honest on charting. A person like this who is obviously malingering, and I would discharge before their butt even hit the bed.

In my chart I would document: "Spoke with patient at length and she voiced no HI, SI, or any medical complaints". You're covered from almost every medical angle. Provided the vital signs are good, you really don't need much more documentation. I always document "no SI or HI" on every psych/homeless patient I discharge, even if they were faking SI to try and get a bed.

 

[KGflyboy]

Don't be overly honest on charting. A person like this who is obviously malingering, and I would discharge before their butt even hit the bed.

In my chart I would document: "Spoke with patient at length and she voiced no HI, SI, or any medical complaints". You're covered from almost every medical angle. Provided the vital signs are good, you really don't need much more documentation. I always document "no SI or HI" on every psych/homeless patient I discharge, even if they were faking SI to try and get a bed.

You must have better triage charting than me. Sometimes I feel like anyone who doesn't smile big enough when checking in gets a documented chief complaint of SI whether it is warranted or not. I sometimes feel like my hands are tied at that point to call psych unless I can make a strong case the patient is ok for discharge despite someone else documenting SI.