Commonly encountered documentation blunders!

[deleted836128]

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We had a bad case in our emergency department recently and upon reviewing the charts from the case, it got me thinking - sometimes, with both our docs and PAs, documentation is very much lacking. Either the doc or PA did something or thought about something but didn’t document that they did, or they missed doing something or considering something entirely. Sometimes I review charts and think “Hmm, this is higher risk and this might end well” and look at the chart and notice that the provider would not have much to defend themselves with if a case went south. What are some common blunders that you notice in charting? I can think of a bazillion, but I will start off the top of my head...

- not addressing abnormal vital signs (you can’t always say “I suspect a viral process” with every unexplained fever)
- not documenting a good hand examination with hand lacerations (sensation and motor function, exploring the lac for tendon involvement or foreign bodies while ranging the digit, checking the strength of FDP AND FDS, whatever)
- not notifying patients about abnormal incidental findings (this one pisses me off THE MOST, hands down... I usually notify the patient, document that they were notified and advised to see PCP for further work up, and add the finding as a diagnosis)
- crappy neuro examinations for back pain patients (I see “CNs intact, normal motor and sensory” - come on, that doesn’t tell anyone you checked reflexes, sensation, strength including plantarflexion and dorsiflexion)... which leads me to...
- not documenting GAIT - if you have a back pain patient that comes in and “can’t walk,” or a hip pain after a fall and you didn’t document you checked that they could walk before they were DCed and the nurse just speeds them out in a wheelchair, we have a problem. I have literally seen patients in bounce back who said that they didn’t walk out of the ER and haven’t walked since, and come back for pain. Makes me wanna smack my head...
- not documenting any significant medical decision making... sometimes I don’t do this but when the history looks suspicious that’s when I really delve into my MDM. For example I had a kid with a left sided sore throat today who said he couldn’t open his mouth all the way because it hurt his throat more. You bet I MDMed the crap out of that based on the reassuring exam - “nontoxic, speaking and swallowing secretions comfortably, opens mouth three finger widths, symmetric tonsils, no uvula shift or fullness of tonsillar pillars, airway widely patent..” and so on. Obviously this can be overkill in some cases but come on!
- not doing good enough AMA documentation - what risks of leaving AMA were explained to the patient? Were they showing adequate decision making capacity? Which brings me to...
- not putting in DC instructions for AMA patients... what, so if they leave AMA they are chopped liver? We should try to set patients up for success with parient education, follow up instructions, prescriptions where indicated, etc and let them know they can come back at any time if things get worse or if they change their mind about further work up
- documenting things that don’t make sense, like a baby is alert and oriented times four, or a pregnant lady’s abdomen is nondistended (technically it’s distended... LOL), or a stroke patient with residual chronic deficits magically has none on exam
- having a tech place a splint and never mentioning in the chart evaluation it before the patient leaves (today I had a guy come in for a second metacarpal fracture and had an ulnar gutter splint placed, not having ANY immobilization effect on the second metacarpal... he came back a second time stating the splint didn’t feel like it was doing anything and was again discharged... WTF! No documentation of splint evaluation by the provider in either note. I saw him today and put him in a radial gutter... in this case it wasn’t an issue of documentation, though; it was carelessness)
- missing MIPS stuff - yes, MIPS is annoying but it’s gone on the back burner and no one seems to be documenting what they need to be documenting
- not documenting that a patient given sedation or narcotics has someone taking them home; also not documenting sedation warnings for prescribed meds (I think only like two other people in my shop do this but isn’t this super important?)

 

[thegenius]

I'm really surprised at the paucity of good documentation in the ER, it happens to all of us. While I would like to think that we do more than we document, for some reason it doesn't get documented. There are a few docs that I work with who only click in Cerner. They do not type in one word at all. Maybe once in a blue moon for consults. Even then...they just write "discussed case". One of them AFAIK has never been sued and he's been doing it for 10+ years.

- not addressing abnormal vital signs (you can’t always say “I suspect a viral process” with every unexplained fever)

This is generally bad...but we have all (and I mean this!) discharged people with mildly abnormal vitals without explanation. Like the young people who come in with HR 108 and some general complaint that wouldn't explain the tachycardia. Like traumatic finger pain. We simply can't keep every single person in the ED with an abnormal vital sign and some stupid complaint and work them all up...all the time. You have traumatic finger pain, you get an xray and go home. I don't care if your HR is between 40-120. Maybe I'll chalk it up to pain.

- not documenting a good hand examination with hand lacerations (sensation and motor function, exploring the lac for tendon involvement or foreign bodies while ranging the digit, checking the strength of FDP AND FDS, whatever)

Re. this: I actually learned something from TeamHealth. They make us do these annual review sessions where we look at Flash-based content about recent lawsuits they've had, and educate us. They are all clinical vignettes. For the past few years we all get the same vignette: a person lacerates their finger and the physician does not document ROM passively AND against resistance. This is for tendon injury. Apparently there was a lawsuit about this. So now I my documentation always reflects movement of the digit passively AND against resistance.

- not notifying patients about abnormal incidental findings (this one pisses me off THE MOST, hands down... I usually notify the patient, document that they were notified and advised to see PCP for further work up, and add the finding as a diagnosis)

Someone once wrote here on SDN about how they add diagnoses to the primary one that indicates all incidental findings and tells them to see their doctor for re-eval of all those diagnoses. I think that is a great idea and want to incorporate that into my practice.

- crappy neuro examinations for back pain patients (I see “CNs intact, normal motor and sensory” - come on, that doesn’t tell anyone you checked reflexes, sensation, strength including plantarflexion and dorsiflexion)... which leads me to...
- not documenting GAIT - if you have a back pain patient that comes in and “can’t walk,” or a hip pain after a fall and you didn’t document you checked that they could walk before they were DCed and the nurse just speeds them out in a wheelchair, we have a problem. I have literally seen patients in bounce back who said that they didn’t walk out of the ER and haven’t walked since, and come back for pain. Makes me wanna smack my head...

Simple macro. I have a "low back pain" macro that I include with all patients. Easy peasy.

- not doing good enough AMA documentation - what risks of leaving AMA were explained to the patient? Were they showing adequate decision making capacity? Which brings me to...
- not putting in DC instructions for AMA patients... what, so if they leave AMA they are chopped liver? We should try to set patients up for success with parient education, follow up instructions, prescriptions where indicated, etc and let them know they can come back at any time if things get worse or if they change their mind about further work up

I don't know if all AMA patients get discharge instructions because they are not discharged. I tell them all to come back if they want another MSE though and document that as such.

- not documenting that a patient given sedation or narcotics has someone taking them home; also not documenting sedation warnings for prescribed meds (I think only like two other people in my shop do this but isn’t this super important?)

I should do this more. Agreed.


It is so hard to put all these things in. Why I hate medicine sometimes. We do things for lawyers and not for medicine.

 

[dadaddadaBATMAN]

Pedantic, but I would argue a pregnant woman’s belly is “Gravid” not “distended.” I would also not write non-distended on a third trimester person though.

I have heard it argued that giving ama folks true discharge instructions gives the impression you were ok with Dc. My instructions always say “please come back at any time if you change your mind about further workup or care.” And my risks of ama are always “death disability and missed diagnosis” unless there’s a fun addition like loss of limb.

In terms of documentation there are too many ****ty ways to document to count. Not sure I have any specific examples

 

[GonnaBeADoc2222]

The examples by ERCAT are good ones.

I also like throwing in certain "observations" in the general section of the PE:
-Patient on cell phone, texting comfortably
-Drinking coffee on presentation
-Laughing with family in exam room
-Watching Netflix without discomfort
-Eating Burger King while complaining of abdominal pain (this happened)

I think it helps to paint a picture of their general "non sickness" and lack of indication for ED presentation.

 

[TooMuchResearch]

Your job is to treat the patient, not be okay with their decision. You give them the best shot at a good outcome. Leaving with STEMI? Rx aspirin. Leaving with sepsis? Rx oral antibiotics. Always with instructions.

Pedantic, but I would argue a pregnant woman’s belly is “Gravid” not “distended.” I would also not write non-distended on a third trimester person though.

I have heard it argued that giving ama folks true discharge instructions gives the impression you were ok with Dc. My instructions always say “please come back at any time if you change your mind about further workup or care.” And my risks of ama are always “death disability and missed diagnosis” unless there’s a fun addition like loss of limb.

In terms of documentation there are too many ****ty ways to document to count. Not sure I have any specific examples

 

[dadaddadaBATMAN]

Your job is to treat the patient, not be okay with their decision. You give them the best shot at a good outcome. Leaving with STEMI? Rx aspirin. Leaving with sepsis? Rx oral antibiotics. Always with instructions.

Agreed, and I do these things. Mitigating harm is always our job regardless of whether someone is being an ass. And I always emphasize that there is increased need to come back if things are worsening. I also document my conversation and my strict returns in my note.

But when you’re giving return precautions on the Dc paperwork I’m telling them I want you to come back at any point if you are willing to. There isn’t much point in saying “come back for” if you don’t want them gone in the first place.

 

[deleted836128]

The examples by ERCAT are good ones.

I also like throwing in certain "observations" in the general section of the PE:
-Patient on cell phone, texting comfortably
-Drinking coffee on presentation
-Laughing with family in exam room
-Watching Netflix without discomfort
-Eating Burger King while complaining of abdominal pain (this happened)

I think it helps to paint a picture of their general "non sickness" and lack of indication for ED presentation.

LOL... I do this too. One of my favorite older docs taught me this early in my ER PA career and I always take it into consideration. A few weeks ago I had a patient with “severe belly pain” taking selfies and I documented that - haha. Not to say it means nothing is wrong with the patient, but it certainly paints a very different picture if someone comes back years down the road claiming they were “in distress.” This doc always told me to “paint a picture” with my charting and it’s one of the best pieces of advice I ever got.

 

[deleted836128]

LOL... I do this too. One of my favorite older docs taught me this early in my ER PA career and I always take it into consideration. A few weeks ago I had a patient with “severe belly pain” taking selfies and I documented that - haha. Not to say it means nothing is wrong with the patient, but it certainly paints a very different picture if someone comes back years down the road claiming they were “in distress.” This doc always told me to “paint a picture” with my charting and it’s one of the best pieces of advice I ever got.

Speaking of this, a couple of weeks ago I had a patient with testicular pain, the US was done and the radiologist mentioned intermittent torsion. I called the patient’s urologist and he said to send the patient home with follow up in the clinic. I also called our on-call urologist who said the same thing. The MD I discussed the case with was confused and so was I, as we just had plans to admit the guy. But when I walked back into the room to talk to the patient, we were talking about what the plan was, and I told him that he would need to see the urologist first thing in the morning and to come back if you experiences any recurrence of pain, and he said “Ummm, question... can I have sex tonight?” pretty much the most awesome question ever and I did document that because again, it paints a very different picture.

 

[southerndoc]

Someone once wrote here on SDN about how they add diagnoses to the primary one that indicates all incidental findings and tells them to see their doctor for re-eval of all those diagnoses. I think that is a great idea and want to incorporate that into my practice.

Probably me. It triggered some posts about it being unnecessary. Diabetes, hypertension, etc. all should be added to the diagnosis list if it's relevant (chest pain, diabetes with lacerations or wounds as it increases risk of impaired healing, etc.). If there is a pulmonary nodule on CT for a trauma patient, they get a diagnosis of "pulmonary nodule seen on computed tomography scan" or multiple nodules diagnosis. Fatty liver also gets a diagnosis. The patients get a list of their diagnoses upon discharge.

You can always come up with more things to add to a chart. I dictate a lot of MDM in my charts, and even when I review them for some reason months later/days later etc (patient returns and I see that I saw them before), I can find things I missed documenting.

Don't over simply things. "No red flags to warrant emergent MRI" on a back pain patient is a no no. Type/dictate what those red flags are that you have ruled out. Trust me, it will be easier to type it now than to come up with it during deposition by the plaintiff when you're under stress. After you incompletely list the red flags during your deposition, the plaintiff will ask "is that all doctor?" When you say yes, you've boxed yourself in at trial. "Doctor, why are you mentioning these things now when you didn't list it during your deposition? In fact, you said there were no other red flags but now miraculously you've come up with another." Part of litigation is not to show that what you did was wrong, but to also undermine your credibility and competence. It's an unfortunate game that the plaintiff's love to play.

 

[deleted109597]

I don't know if all AMA patients get discharge instructions because they are not discharged. I tell them all to come back if they want another MSE though and document that as such.

If they go AMA, you can still give them instructions. And RX.
And you should. You're trying to give them their best outcome on their terms. Not the angry nursing screed of "get out you ungrateful bastard". Bad infection? Still gets antibiotics. STEMI? As above (I wouldn't give them plavix or anything). PE or whatever? Anticoagulants.
Also, always write in there that they can come back if they choose, and that they should if the condition worsens.

 

[thegenius]

I help most people who go AMA, especially if they want to be helped.

There is a spectrum of elopement / AMA in the ED. On one end, the patient screams and yells at you, cusses, and is outright unruly and sometimes bordering on being aggressive and they either storm out or are escorted out. I'm not printing discharge papers and Rx's for them.

Then there are those who have a problem that I think needs admission, the patient doesn't want to be....and the pt explains why. It makes sense to me and I tell the patient "I would like to you to sign AMA paperwork, but I will help you as much as possible" and give them everything they need, including future appointments too if necessary.

 

[thegenius]

Don't over simply things. "No red flags to warrant emergent MRI" on a back pain patient is a no no. Type/dictate what those red flags are that you have ruled out. Trust me, it will be easier to type it now than to come up with it during deposition by the plaintiff when you're under stress. After you incompletely list the red flags during your deposition, the plaintiff will ask "is that all doctor?" When you say yes, you've boxed yourself in at trial. "Doctor, why are you mentioning these things now when you didn't list it during your deposition? In fact, you said there were no other red flags but now miraculously you've come up with another." Part of litigation is not to show that what you did was wrong, but to also undermine your credibility and competence. It's an unfortunate game that the plaintiff's love to play.

Macros and templates are good for several reasons...and one of them serves to remind you of all the "red flags" or emergency diagnoses. I have one for low back pain. I have an extensive template for low back pain with columns of muscles and numbers 1 thru 5 (kind of looks like a neurosurgery template). There are others too.

Gotta be careful though...a buddy of mine has a lower abd pain macro and in it says "ectopic pregnancy" and he will occasionally use that for males. 🙂

 

[TooMuchResearch]

The biggest pile of abx I've ever prescribed was for an AMA septic elbow in residency. All the Bactrim and Keflex.

If they go AMA, you can still give them instructions. And RX.
And you should. You're trying to give them their best outcome on their terms. Not the angry nursing screed of "get out you ungrateful bastard". Bad infection? Still gets antibiotics. STEMI? As above (I wouldn't give them plavix or anything). PE or whatever? Anticoagulants.
Also, always write in there that they can come back if they choose, and that they should if the condition worsens.

 

[deleted109597]

There is a spectrum of elopement / AMA in the ED. On one end, the patient screams and yells at you, cusses, and is outright unruly and sometimes bordering on being aggressive and they either storm out or are escorted out. I'm not printing discharge papers and Rx's for them.

The only reason mine don't get them is if they leave without them. And even then, I put in a note saying that, and that they're left at the front desk for the patient should they choose to get them.
I don't go out of my way to thrust them in their hands, but even people removed by LEOs can have medical emergencies.

 

[Groove]

Documenting a repeat neurovascular exam after the splint has been applied. I reviewed a case in the past couple of years where a PA applied a finger splint (or had a tech apply the finger splint) and the pt showed up in an ortho's office with a gangrenous, necrotic finger that had to be amputated because the splint was applied way too tight. (Not my case, I wasn't involved) but after I reviewed it I got very paranoid about rechecking splints applied by techs (we should all be doing this anyway) and checking MLPs splints if they have an ortho case that I know about.

Otherwise, great examples. Always take a couple extra minutes to document defensively. I hate saying it but I think about this every shift while I'm documenting. If you have a particular case where you perceive a higher litigation potential (unhappy patients, threatening patients, etc..) always save that chart until your shift is over and go through it while you aren't rushed to maximizing your defensive documentation. You'd be surprised how this can save your butt sometimes.

As for AMA, RMM recently discussed an article from TrendMD on the topic and the general consensus was that it needs to include 5 components (if possible):
1. The pt is an adult or emancipated minor.
2. The pt has capacity.
3. The pt has been informed of the potential consequences of non-treatment.
4. Family and friends have been involved in the decision.
5. The AMA form (which includes a statement that leaving against medical advice may result in death or disability) is signed by the pt, the physician, a witnessing ED staff member, and a family member of the pt if available.

I can't find the original article on TrendMD, but here's a related link:

Patient’s Signature on AMA Form Won’t Stop Successful Lawsuit |…

If a patient wants to leave the ED against medical advice (AMA), he or she typically has to sign the “AMA form.” But how much legal protection does this really provide the EP? “Very little,” without any additional supporting documentation, Marc E. Levsky, MD, warns. “A case where the plaintiff left…

www.reliasmedia.com

Levsky advises including these notes in the ED chart:

• The patient possessed the capacity to refuse further care;
• The patient understood the possible consequences of his or her departure;
• How the EP established that the patient demonstrated normal mental status, was not intoxicated, and was not psychotic or suicidal;
• Which person discussed the possible diagnoses and recommendations with the patient;
• How the patient responded to the recommendations;
• Efforts made to convince the patient not to leave;
• The patient was advised to return at any time if further care is desired;
• A short-term follow-up plan.

The consensus being...don't overly rely on the AMA form but instead paint a narrative in your note that supports critical communication and competent decision making on the pt's part while providing alternatives in care (don't write the pt off because they are leaving AMA...refuse to fill their meds or provide f/u, etc..)

 

[southerndoc]

I always try to reevaluate splints placed by techs. That's far out that they put the splint on so tight that it resulted in gangrene. Was there an arterial injury with the finger fracture or was it all due to the splint being so tight?

That's a good recommendation to wait until the end of a shift for problem patients. Frequently I dictate and sign as soon as I can, which often is before the patient has truly left the department (when I've clicked the dispo tab).

 

[deleted836128]

Documenting a repeat neurovascular exam after the splint has been applied. I reviewed a case in the past couple of years where a PA applied a finger splint (or had a tech apply the finger splint) and the pt showed up in an ortho's office with a gangrenous, necrotic finger that had to be amputated because the splint was applied way too tight. (Not my case, I wasn't involved) but after I reviewed it I got very paranoid about rechecking splints applied by techs (we should all be doing this anyway) and checking MLPs splints if they have an ortho case that I know about.

Otherwise, great examples. Always take a couple extra minutes to document defensively. I hate saying it but I think about this every shift while I'm documenting. If you have a particular case where you perceive a higher litigation potential (unhappy patients, threatening patients, etc..) always save that chart until your shift is over and go through it while you aren't rushed to maximizing your defensive documentation. You'd be surprised how this can save your butt sometimes.

As for AMA, RMM recently discussed an article from TrendMD on the topic and the general consensus was that it needs to include 5 components (if possible):
1. The pt is an adult or emancipated minor.
2. The pt has capacity.
3. The pt has been informed of the potential consequences of non-treatment.
4. Family and friends have been involved in the decision.
5. The AMA form (which includes a statement that leaving against medical advice may result in death or disability) is signed by the pt, the physician, a witnessing ED staff member, and a family member of the pt if available.

I can't find the original article on TrendMD, but here's a related link:

Patient’s Signature on AMA Form Won’t Stop Successful Lawsuit |…

If a patient wants to leave the ED against medical advice (AMA), he or she typically has to sign the “AMA form.” But how much legal protection does this really provide the EP? “Very little,” without any additional supporting documentation, Marc E. Levsky, MD, warns. “A case where the plaintiff left…

www.reliasmedia.com

Levsky advises including these notes in the ED chart:

• The patient possessed the capacity to refuse further care;
• The patient understood the possible consequences of his or her departure;
• How the EP established that the patient demonstrated normal mental status, was not intoxicated, and was not psychotic or suicidal;
• Which person discussed the possible diagnoses and recommendations with the patient;
• How the patient responded to the recommendations;
• Efforts made to convince the patient not to leave;
• The patient was advised to return at any time if further care is desired;
• A short-term follow-up plan.

The consensus being...don't overly rely on the AMA form but instead paint a narrative in your note that supports critical communication and competent decision making on the pt's part while providing alternatives in care (don't write the pt off because they are leaving AMA...refuse to fill their meds or provide f/u, etc..)

This case seems...unbelievable. How could that even happen? It's a friggin' finger splint and you would think the patient would notice something amiss and loosen the splint. Splints are wrapped with adjustable materials, so how do we know the patient didn't tighten the splint after discharge? Still, this is spooky. I usually document "I reevaluated the splint after placement to ensure intact neurovascular status" (very vague) but I honestly don't do this with finger splints...maybe I should...geez.

I will be honest; I document four out of those five points all the time. If the family or a friend is there, I will mention that. However, if the patient is alone, I don't go out of my way to call the family. I don't feel like I have that right.

 

[Xerxes1729]

I would consider adding something to your AMA template about how the patient was informed of their right to a medical screening exam and stabilization of any emergency medical conditions under EMTALA, and that the patient declined the screening and/or stabilization. I don't think it adds much to protect you from a plaintiff's attorney over what most of us already write, but it's what the feds care about if they come sniffing around. Not that I would know anything about that.

 

[doctalaughs]

Just to play devils advocate here-
How many thousands of extra hours do we doctors spend documenting to “possibly” avoid a bad lawsuit, and is it worth it? I know it’s the environment we practice in, but sometimes I wonder if spending more time with the patients and having just a very brief note (mainly to convey info to the next doc) would result in a better system.

I know - not possible for various reasons but one can dream.... imagine doing a great work up and exam, talking to the patient and writing just a few lines in the chart! Imagine how efficient healthcare would be.

 

[thegenius]

Just to play devils advocate here-
How many thousands of extra hours do we doctors spend documenting to “possibly” avoid a bad lawsuit, and is it worth it? I know it’s the environment we practice in, but sometimes I wonder if spending more time with the patients and having just a very brief note (mainly to convey info to the next doc) would result in a better system.

I know - not possible for various reasons but one can dream.... imagine doing a great work up and exam, talking to the patient and writing just a few lines in the chart! Imagine how efficient healthcare would be.

That, above, is probably one of the reasons why a colleague of mine spends so little time on charting. There is an estimate that 1/40,000 ER charts gets a lawsuit. I estimate the average ER doc writes ~4,000 charts / year. So you might get sued once every 10 years.

So you can spend 10-15 minutes a chart, padding it, making it perfect, which would take an extra 40,000 - 60,000 minutes a year.
Or you can spend 1 minute clicking on buttons, which would cost you 4,000 minutes a year, and you save 10 fold the amount of time for an event that is very rare.

(and of note, I'm not advocating one way or the other).

[ Or you can get real good at charting and spend 1 minute padding it, making it perfect and save a lot of time too. ]

 

[Groove]

I always try to reevaluate splints placed by techs. That's far out that they put the splint on so tight that it resulted in gangrene. Was there an arterial injury with the finger fracture or was it all due to the splint being so tight?

That's a good recommendation to wait until the end of a shift for problem patients. Frequently I dictate and sign as soon as I can, which often is before the patient has truly left the department (when I've clicked the dispo tab).

I say "splint" but it appeared to be a dressing/bandage without any aluminum splint used. The orthopedist actually had pictures. I couldn't tell what was used to wrap it under the ace bandage but it was so tight that the fabric pattern was tattooed onto the skin. Apparently it had been a laceration repair (not a fracture) and was wrapped that tight as a pressure bandage to keep the wound from bleeding. They may have received a digit block which would explain why they didn't rip it off sooner. It was nuts.

 

[Old_Mil]

In the end, documentation takes your time and is subjective.

Testing, on the other hand, takes someone else's time and is objective.

One normal test result is worth a thousand lines of text.

Remember, your job is not to save the system.

Probably me. It triggered some posts about it being unnecessary. Diabetes, hypertension, etc. all should be added to the diagnosis list if it's relevant (chest pain, diabetes with lacerations or wounds as it increases risk of impaired healing, etc.). If there is a pulmonary nodule on CT for a trauma patient, they get a diagnosis of "pulmonary nodule seen on computed tomography scan" or multiple nodules diagnosis. Fatty liver also gets a diagnosis. The patients get a list of their diagnoses upon discharge.

...and yes, absolutely. Any incidentalomas must be documented.

I used to be pretty religious about documenting arrival and discharge vitals in the chart...however the biggest obstacle to this is nursing staff not doing/charting them.

 

[Old_Mil]

If they go AMA, you can still give them instructions. And RX.
And you should.

I make a point of not documenting a diagnosis in my AMA charts that the patient left before a diagnostic workup/medical screening exam could be initiated or completed and as a result no diagnosis could be made. I would say that writing prescriptions in this setting could be a potentially dangerous practice...

Oh, and while I'm at it, be very careful about documenting medical decision making. While I'll often throw in a few lines of text to clarify why I'm doing what I'm doing for a patient, I absolutely positively NEVER chart a list of differential diagnoses. Instead I actually ask and chart multiple negative findings on the ROS to try and paint that picture of good or ill health objectively based on symptoms.

 

[thegenius]

I make a point of not documenting a diagnosis in my AMA charts that the patient left before a diagnostic workup/medical screening exam could be initiated or completed and as a result no diagnosis could be made. I would say that writing prescriptions in this setting could be a potentially dangerous practice...

Oh, and while I'm at it, be very careful about documenting medical decision making. While I'll often throw in a few lines of text to clarify why I'm doing what I'm doing for a patient, I absolutely positively NEVER chart a list of differential diagnoses. Instead I actually ask and chart multiple negative findings on the ROS to try and paint that picture of good or ill health objectively based on symptoms.

Why? Do you feel that if you list a diagnosis in your differential that it must be worked up?

Because it is totally reasonable to exclude a diagnosis based on H&P. You don't necessarily need to order tests to do so (depending on what the diagnosis is).

 

[RustedFox]

That, above, is probably one of the reasons why a colleague of mine spends so little time on charting. There is an estimate that 1/40,000 ER charts gets a lawsuit. I estimate the average ER doc writes ~4,000 charts / year. So you might get sued once every 10 years.

So you can spend 10-15 minutes a chart, padding it, making it perfect, which would take an extra 40,000 - 60,000 minutes a year.
Or you can spend 1 minute clicking on buttons, which would cost you 4,000 minutes a year, and you save 10 fold the amount of time for an event that is very rare.

(and of note, I'm not advocating one way or the other).

[ Or you can get real good at charting and spend 1 minute padding it, making it perfect and save a lot of time too. ]

Great post.

Allow me to respond.

I read every MLP chart that comes to me. I correct (close to) every error that I identify.

Three reasons:

1.) This is bad for the patient. If the care isn't up to snuff, or is up to snuff and isn't documented as such... the patient loses.
2.) This is bad for the MLP. If they don't know what they're doing isn't up to snuff, then they'll never change their ways.
3.) This is bad for the physician. Signing a chart blindly where the care documented is clearly not up to snuff results in you saying: "Yeah, I didn't actually read the document, but I signed it." That's indefensible.

Thus: NOBODY wins when you don't read the chart, and the chart sucks.

You can argue that you (the physician) wins because you don't spend more time/energy reviewing charts than you "have to" and the actual relative risk is very small... but... refer to my three statements above.

You all saw my copy-pasted HPI on here that I had to read from an MLP chart recently: "The patient presents with Vision" Someone posted a GIF of a red and black skinned robot-creature opening his eyes and turning his head left to emphasize the ridiculum of the statement. Those posts are brilliant, and give weight to my bottom line:

If I have to sign your chart; you do as I say and document as such. No excuses. Then and only Then can I defend your care.

I got word last week that the MLP that gave insulin (but not glucose) to the hyperkalemic 22 year old landscaper in renal failure took a job in another health system, because he/she found the contract with our new *alt-CMG* unpalatable because of the lack of autonomy.

My reaction was: "Good Riddance! Go cause somebody else a lawsuit with your inability to follow even basic directions in the environment of "optimal team practice"!"

These MLPs, man. There are good ones and bad ones. Just like there are good docs and bad docs. The difference is: the MLPs have someone else to eat their mistakes, and don't like to hear that they've made mistakes when "Doctor OtherGuy says it okay that I do this!"

Hard. Stop.

*Whistle!* Land on my shoulder, MLP. Together, we can do amazing things. Should you fly alone, then I cannot help you from yourself, especially when you do not take commands.

 

[GonnaBeADoc2222]

Great post.

Allow me to respond.

I read every MLP chart that comes to me. I correct (close to) every error that I identify.

Three reasons:

1.) This is bad for the patient. If the care isn't up to snuff, or is up to snuff and isn't documented as such... the patient loses.
2.) This is bad for the MLP. If they don't know what they're doing isn't up to snuff, then they'll never change their ways.
3.) This is bad for the physician. Signing a chart blindly where the care documented is clearly not up to snuff results in you saying: "Yeah, I didn't actually read the document, but I signed it." That's indefensible.

Thus: NOBODY wins when you don't read the chart, and the chart sucks.

You can argue that you (the physician) wins because you don't spend more time/energy reviewing charts than you "have to" and the actual relative risk is very small... but... refer to my three statements above.

You all saw my copy-pasted HPI on here that I had to read from an MLP chart recently: "The patient presents with Vision" Someone posted a GIF of a red and black skinned robot-creature opening his eyes and turning his head left to emphasize the ridiculum of the statement. Those posts are brilliant, and give weight to my bottom line:

If I have to sign your chart; you do as I say and document as such. No excuses. Then and only Then can I defend your care.

I got word last week that the MLP that gave insulin (but not glucose) to the hyperkalemic 22 year old landscaper in renal failure took a job in another health system, because he/she found the contract with our new *alt-CMG* unpalatable because of the lack of autonomy.

My reaction was: "Good Riddance! Go cause somebody else a lawsuit with your inability to follow even basic directions in the environment of "optimal team practice"!"

These MLPs, man. There are good ones and bad ones. Just like there are good docs and bad docs. The difference is: the MLPs have someone else to eat their mistakes, and don't like to hear that they've made mistakes when "Doctor OtherGuy says it okay that I do this!"

Hard. Stop.

*Whistle!* Land on my shoulder, MLP. Together, we can do amazing things. Should you fly alone, then I cannot help you from yourself, especially when you do not take commands.

How much unpaid time are you spending doing this?

 

[Groove]

I read every MLP chart that comes to me. I correct (close to) every error that I identify.

Three reasons:

1.) This is bad for the patient. If the care isn't up to snuff, or is up to snuff and isn't documented as such... the patient loses.
2.) This is bad for the MLP. If they don't know what they're doing isn't up to snuff, then they'll never change their ways.
3.) This is bad for the physician. Signing a chart blindly where the care documented is clearly not up to snuff results in you saying: "Yeah, I didn't actually read the document, but I signed it." That's indefensible.

Thus: NOBODY wins when you don't read the chart, and the chart sucks.

How are you correcting the notes? Are you documenting PE components, etc.. that weren't present in the original note? Or do you mean you are sending them back to the MLP to correct/add/subtract certain components?

If I change anything in a MLPs note, it doesn't get sent back to them unless I put a note in there to send it back for correction. Therefore, I rarely alter anything they've entered as it would be fraudulent.

 

[RustedFox]

How much unpaid time are you spending doing this?

Great question. Deserves a great answer.

I don't ever log-in after a shift to sort out MLP care. Once I'm out; I'm out. See yah!

Generally, when I log-in for my next shift, I review the MLP charts over the first hour of my shift.
I make addendums where I need to.
I take note of the actionable items when I need to.
I make callbacks.
I call the MLPs.
I sort it out.

Here's the beauty:

With the loss of TeamHEALTH [at my main job site] and the loss of a mothership for the MLPs to run to when they do stupid things, things are changing radically.

We used to have one doc in the afternoon, with 2 MLPs in support.

We got sick of the MLPs being entirely inadequate with even small ****.

We now have two physicians in the afternoon, and one MLP.

The MLP's directive is: "see stupid stuff quickly, and then take orders from the physician assigned to you. No arguments."

The physicians "cover" every bed in the ER, which is appropriate... as we are responsible for the care. The MLP only serves to assist at our direction, as an MLP should do.

"Physician Assistant"? Okay. Assist me. Do as I say.

"Nurse Practitioner"? Same gig. Do as I say. You don't like it? Okay. You're fired. Byeee. Go ruin primary care.

...


...


...


My wife had an intake appointment with her new family care centre this week.

Didn't see a physician. Saw the "Nurse Practicioner".

My wife is a decorated biochemist. Worked with Merck on things like "Gardasil"... "QuadPro".. etc.

She came home and said: "I could tell that the NP didn't pass high-school chemistry."


Done.

 

[GonnaBeADoc2222]

Great post.

Question though: For that first hour, what about the patients that have been waiting? Do you colleagues get annoyed that you take an hour to do this? Or maybe you are picking up a few and getting labs/imaging started before you actually see them? Also are you straight hourly or also RVU?

 

[GonnaBeADoc2222]

Great question. Deserves a great answer.

I don't ever log-in after a shift to sort out MLP care. Once I'm out; I'm out. See yah!

Generally, when I log-in for my next shift, I review the MLP charts over the first hour of my shift.
I make addendums where I need to.
I take note of the actionable items when I need to.
I make callbacks.
I call the MLPs.
I sort it out.

Here's the beauty:

With the loss of TeamHEALTH [at my main job site] and the loss of a mothership for the MLPs to run to when they do stupid things, things are changing radically.

We used to have one doc in the afternoon, with 2 MLPs in support.

We got sick of the MLPs being entirely inadequate with even small ****.

We now have two physicians in the afternoon, and one MLP.

The MLP's directive is: "see stupid stuff quickly, and then take orders from the physician assigned to you. No arguments."

The physicians "cover" every bed in the ER, which is appropriate... as we are responsible for the care. The MLP only serves to assist at our direction, as an MLP should do.

"Physician Assistant"? Okay. Assist me. Do as I say.

"Nurse Practitioner"? Same gig. Do as I say. You don't like it? Okay. You're fired. Byeee. Go ruin primary care.

...


...


...


My wife had an intake appointment with her new family care centre this week.

Didn't see a physician. Saw the "Nurse Practicioner".

My wife is a decorated biochemist. Worked with Merck on things like "Gardasil"... "QuadPro".. etc.

She came home and said: "I could tell that the NP didn't pass high-school chemistry."


Done.

Similarly, my wife was establishing care with an obgyn when we relocated. Former chief resident, very smart. ICU badass. When she called, they said Great! We will get you an appointment with Jenny McJennerson right away. My wife asked is this a physician or an NP.? Oh, it's an NP? Nope. I want to see the physician.

My wife: "why would I see someone that I know more about medicine than?"

I teared up with pride.

 

[RustedFox]

Similarly, my wife was establishing care with an obgyn when we relocated. Former chief resident, very smart. ICU badass. When she called, they said Great! We will get you an appointment with Jenny McJennerson right away. My wife asked is this a physician or an NP.? Oh, it's an NP? Nope. I want to see the physician.

My wife: "why would I see someone that I know more about medicine than?"

I teared up with pride.

"Jenny McJennyson" is catching on.

I'm so proud. *Sniff*.

But for real: these community NPs.... they're more dangerous to medicine than the patients that they serve.

 

[deleted109597]

I make a point of not documenting a diagnosis in my AMA charts that the patient left before a diagnostic workup/medical screening exam could be initiated or completed and as a result no diagnosis could be made. I would say that writing prescriptions in this setting could be a potentially dangerous practice...

So there's AMA, and there's LBTC (left before treatment complete). LBTC is elopement. They might get some instructions on what I thought they had, and why I thought they needed it, and failure to do so could result in permanent disability, disfigurement, seizurecomadeath.
But AMA is generally "I want to admit you to the hospital" and they say no. Occasionally it's "I want to send you somewhere via ambulance" and they say "I'd rather drive my own car". I can't make them do it. I just tell them it's a bad idea (and suffer some of the responsibility of course). Rarely does someone AMA because they don't want the CT.
Elopements typically leave before they get instructions anyway.

 

[RustedFox]

Great post.

Question though: For that first hour, what about the patients that have been waiting? Do you colleagues get annoyed that you take an hour to do this? Or maybe you are picking up a few and getting labs/imaging started before you actually see them? Also are you straight hourly or also RVU?

I'm actively seeing patients at the same time I'm reviewing MLP charts and such.

Hourly + RVU, to answer your second question.

 

[RustedFox]

How are you correcting the notes? Are you documenting PE components, etc.. that weren't present in the original note? Or do you mean you are sending them back to the MLP to correct/add/subtract certain components?

If I change anything in a MLPs note, it doesn't get sent back to them unless I put a note in there to send it back for correction. Therefore, I rarely alter anything they've entered as it would be fraudulent.

The chart gets sent back to the MLP if its something that needs to be completed (physical exam that's not there, diagnosis isn't there, etc)
Telephone follow-ups are made to ascertain just what exactly happened. I don't "edit" any part of the H&P that I didn't do, but I will import labs or studies if they don't do that.

 

[thegenius]

"Jenny McJennyson" is catching on.

I'm so proud. *Sniff*.

But for real: these community NPs.... they're more dangerous to medicine than the patients that they serve.

I still think MacKenzie is hotter than Jenny. But just by a little bit.