Do you list differentials in your ED notes?

[Fox800]

Polling the hive-mind here. The culture at my residency program is make a list of your differentials, something to the effect of "DDx: ACS, pulmonary embolism, thoracic aortic dissection, pneumothorax, pneumonia..."

I rotated at a community hospital recently and got chided for doing that. I was told to not make a list because we didn't necessarily work up everything fully in that list (i.e. thought about PE but didn't do a CT pulmonary angiogram) because it exposes you to medicolegal liability.

Since then I've been doing it in a more conversational way, kind of explaining my differential in full sentences in my MDM, or at least mentioning testing that I did related to my differential...i.e. "12-lead ECG without ischemic changes and normal troponin x2", "no cough, fever, or infiltrate on CXR", "Wells PE Score 1 with negative D-dimer" instead of making a list.

What do you do in practice? Just looking for some tips to chart more efficiently, in a legally defensible matter.

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[fahimaz7]

Polling the hive-mind here. The culture at my residency program is make a list of your differentials, something to the effect of "DDx: ACS, pulmonary embolism, thoracic aortic dissection, pneumothorax, pneumonia..."

I rotated in at a community hospital recently and got chided for doing that. I was told to not make a list because we didn't necessarily work up everything fully in that list (i.e. thought about PE but didn't do a CT pulmonary angiogram) because it exposes you to medicolegal liability.

Since then I've been doing it in a more conversational way, kind of explaining my differential in full sentences in my MDM, or at least mentioning testing that I did related to my differential...i.e. "12-lead ECG without ischemic changes and normal troponin x2", "no cough, fever, or infiltrate on CXR", "Wells PE Score 1 with negative D-dimer" instead of making a list.

What do you do in practice? Just looking for some tips to chart more efficiently, in a legally defensible matter.

Either works. It's your note.

 

[WilcoWorld]

I do not do this for very straight-forward cases, but when there is ambiguity I will reiterate the pertinent negatives in my MDM. e.g.: An abdominal pain pt where imaging wasn't done I'll often note "Patients is afebrile, has no TTP at McBurney's, has a negative Murphy's and a negative lipase."

I think it can go either way. If you really did thoughtfully consider each item on that DDx, and you can point to something in your chart that supports not doing it, then this practice almost certainly protects you (and probably protects your patients) from bad outcomes. On the other hand, if you're just using macros that insert "Considered PE, dissection, pericarditis, Boerhaave's, PTX, ACS" into every chest pain chart - but you aren't actually thinking about all of those and addressing them elsewhere in the chart - then it probably does open you up to liability in the case that you're wrong.

So, that raises the question - how are you using the DDx list in your charting? Thoughtfully, or on autopilot?

 

[witzelsucht]

my program is big on the "laundry list" (i'm pg1). so i have started doing it more compared to my medical school charting style. my "practice pattern" from being a community scribe is more like what you describe - listing pertitnent pos/neg as MDM so that it is not directly saying "i'm blowuing off PE" but will list = "cp, multiple risk factors for acs incluing smoking, ekg, +fhx; no travel/estrogen/leg pain, no vomiting, no sob no pleuritic pain, equal BP in arms" so that it shows i thought about other things

 

[da8s0859q]

Stopped doing this at some point in residency. Mental masturbation after awhile.

I do what's described above -- demonstrate you thought about the other things and why you didn't go chasing them with CTA or whatever else. We may not be perfect, but a well-reasoned, explained approach is best.

 

[RNR]

For moderately complex patients (abd pain, chest pain, neuro complaints, etc.) being discharged I have a macro that reads something like -

"I have considered emergency causes of this patient's symptoms including but not limited to:
X
Y
Z
Etc.
I feel they are unlikely because of:
P
D
Q"

I write shorter MDM notes on patients being admitted justifying their need for admission. I feel there's much more risk present in patients being discharged than those being admitted. I tend to write short notes in general, with the driver being more focused on risk rather than billing.

 

[Daiphon]

Stopped doing this at some point in residency. Mental masturbation after awhile.

I do what's described above -- demonstrate you thought about the other things and why you didn't go chasing them with CTA or whatever else. We may not be perfect, but a well-reasoned, explained approach is best.

Agree here. I only ddx the considered life threats, and why/why not pursued.

Typically a "treat & street" is evident from my Hx/Ex, so doesn't need the exposition.

Semper Brunneis Pallium

 

[EMDOC17]

If I list Ddx I usually keep it broad i.e. considered infectious vs. metabolic causes. Granted for chest pain I usually list specific causes i.e ACS, PE, Dissection, ect. I don't think it is bad to list Ddx but have to say why you don't think it is X. Either by testing or by physical exam. I often list aortic dissection in my differential for chest pain. Did I test for it? no. I say I don't think it is that because of no pain to the back, not hypertensive, equal pulses and blood pressure in the arms. I didn't test for it but it makes it known that I looked for it and ruled it out on my PE. Same with abdominal pain. "I considered appendicitis but their pain is generalized and not focal to the RLQ or umbilicus. Furthermore their history does not fit with appendicitis therefore I think this is very unlikely. Consoled patient on x,y, and Z that would be concerning for appendicitis and those reasons that they should return to the ED."

 

[diphenyl]

I have macro's for my ddx. Picis has a seperate section for it. On epic i will just put it as a little blurb. I have preformed ones for chest pain, sob, upper abd pain, vag bleeding. Just the bread and butter ones. I always preface it with "diferential daignosis including but not limited to a,b,c etc

 

[DeadCactus]

The problem with notes is that there is no evidence to support the best way to do it and the legal process is not reproducible in a way that allows for evidence based practices. The best you can do is see where other people were burned. As a resident, write it how you're attending wants. As an independent physician, you have to decide what lets you sleep at night. Personally, I would find it easier to defend saying I thought about something but found it so clinically unlikely that I didn't test for it than trying to defend not considering it or "I swear I thought about, I just didn't write it down". I focus my documentation on things I thought, my physical and exam, and conversations I had because my note is the only proof I have those things happened.

 

[BAM!]

Anyone who has been sued like to share if they wished they had written something more about their differential diagnosis?

 

[deleted109597]

On a t sheet, the backslashes in the diagnosis box is a MDM/DDX esque thing. IE if you slashed it, you've ruled it out. Doesn't have much in it but it's more than anything.

 

[Janders]

I certainly don't for the fast track stuff.

But for complicated things, of course I do. Adds to the complexity of the MDM for billing purposes. Explains to the inpatient team what the heck you were thinking. I don't mean a 48 point bulleted list, but perhaps:

"48M 3d s/p intrabd surgery p/w sudden severe pain epigastric and low chest pain, syncope PTA, and tachycardia on initial assessment. Initially Ddx included significant PE, post-operative bleeding, less causes not limited to ACS, toxic/metabolic causes, dehydration with post-operative pain, etc. Initial EKG was non-ischemic. Plan for large bore IV access, resuscitation, analgesia, urgent CTA torso, board labs, maintain on tele and reassess."

That said I'm not going to write "maybe its a PE?" without then addressing why I did not test for it...

As mentioned above, there is no good "standard" for this.

 

[Tiger26]

I explain that I don't think it is x,y, or z. For example, in common chest pain, I'll say something to the effect of "based on the symptoms, history, and exam, I don't believe the patient's symptoms are consistent with ACS, a PE, aortic dissection, esophageal rupture, pneumothorax, pneumonia, CHF, or a referred intra-abdominal process. This is usually further explained based on tests and other discussion in my medical decision making.

In contrast, I get really irritated when the residents just list a laundry list of diagnoses and then either fail to explain anywhere why they are not consistent with the presentation, or at least test for them.

 

[joeDO2]

I tend to list out and/or explain justifications for diagnoses that I am not getting a specific test for. I feel like my orders are documentation that I have thought of certain things- for example if I am getting a lipase and lfts on a belly pain, I feel that that order is showing I'm considering pancreatic / biliary pathology. Similarly, if I have an order in the chart for a CTA with r/o PE in the indication, that seems sufficient for showing that I am thinking about that.

 

[BAM!]

The best thing is clearly to list each item and explain why you think it is or isn't likely.

However, due to time constraints this is impractical. So it's best to pick and choose which to chart more thoroughly.

However, many times when people are sued, they think... "That case?! That was nothing!!" A case which didn't seem high risk at the time.

Therefore, I think it's better to include a laundry list of ddx instead of NOT including it. Even if you don't explicitly say in the MDM why you do or don't think it's an aortic dissection, for example, at least you have expressed consideration about this diagnosis. For example, if your charting reflects pain not typical for aortic dissection (R lateral chest pain for 5 seconds, reproducible, self resolved, no hypertension, no murmurs, no distress, etc.), then you have a legitimate argument that you didn't think it was aortic dissection and your history and physical supports that line of thinking. However, if you never even considered aortic dissection, pulmonary embolism, acute coronary syndrome, etc, well that's negligence.

BEST --> list everything and explain why it is or isn't.
GOOD --> to at least list a DDx
BAD --> to not list any type of DDx

Just make sure you don't write all sorts of details about sudden onset chest pain radiating to the back in massive distress with hypertension and syncope plus unequal blood pressures in each arm, then include aortic dissection in your ddx and send them home without further addressing it with your studies.

 

[Tenk]

Yes and no. Obviously if someone has appendicitis I don't list a bunch of other useless things.

I think the ddx is good when you don't actually have a clear cut diagnosis for instance an undifferentiated chest pain. Then I start listing lethal diagnoses and how I ruled them out. Just listing a bunch of random crap without ruling out said random crap is pretty useless, stupid, and just looks like you are covering your ass rather than putting forth some compassionate thought like you actually care.

That's my take!

 

[TooMuchResearch]

I tend to list out and/or explain justifications for diagnoses that I am not getting a specific test for. I feel like my orders are documentation that I have thought of certain things- for example if I am getting a lipase and lfts on a belly pain, I feel that that order is showing I'm considering pancreatic / biliary pathology. Similarly, if I have an order in the chart for a CTA with r/o PE in the indication, that seems sufficient for showing that I am thinking about that.

Are your coders okay with that? I don't think ours looks through our indications, and they aren't trained to know why one would obtain certain studies.

 

[BAM!]

Just listing a bunch of random crap without ruling out said random crap is pretty useless

All this stuff is useless. when reading a note, everyone skips most of the HPI, ROS, PE, social and family history. 90% is CYA. Yes, chart bloat sucks. We all agree on that. But when you're writing your letter to the lawyers, you can tell them you thought about several important diagnoses quickly and efficiently.

 

[Old_Mil]

I rotated at a community hospital recently and got chided for doing that. I was told to not make a list because we didn't necessarily work up everything fully in that list (i.e. thought about PE but didn't do a CT pulmonary angiogram) because it exposes you to medicolegal liability.

I don't, the above explanation is why I don't. Also keep in mind that if you put in the chart that you thought about X, ruled it out, and X ends up killing the patient all that does is impugn your competence in writing - particularly if you ruled it out clinically without running tests to rule it out. Keep in mind that as a physician nobody cares about your so called education, training, history and physical. If something goes wrong, it's all about the tests you did or failed to order.

Where I do it is indirectly, with a bunch of negatives in the review of systems. That gives you the ability to say the patient said they didn't have x,y, and z without directly assembling a list of diagnoses which didn't include what ends up resulting in the bad outcome. I've seen people mail in the ROS on EMRs by blanket checking "all negative", and I don't think that's a good idea.

Remember, you're a pinata and the lawyers have the sticks.

 

[Old_Mil]

Are your coders okay with that? I don't think ours looks through our indications, and they aren't trained to know why one would obtain certain studies.

With a lot of EMRs it's really easy to see if you've included enough information to boost the chart to a level five, even for fast track stuff. Once you do that, the coders are happy and they can figure out what to level something as.

 

[xaelia]

I tend to agree with most posters above it probably doesn't matter what you write from a medicolegal standpoint – the lawyers will get theirs, someway, somehow.

From a personal opinion standpoint, if you truly considered a diagnosis sufficiently to list it in your differential, you should also have some corresponding charting addressing either how it was ruled-out to the standard of care, or why you felt the work-up was low yield/likely to cause more harm than benefit etc.

 

[Angry Birds]

Everyone at my hospital lists D/Dx except for me. I took it out of the boiler plate note. I have heard from a senior EM physician--who does lots of expert witness stuff--that if you don't mention something in your list, and it turns out to be that, then that can be bad for you. "Doctor, didn't you think of XYZ? If you did, why isn't in your long list?" Meanwhile, if you don't have any list at all, then you can just say, "Of course I thought of that. I always consider that."

Personally, I don't feel listing something in a D/Dx protects you in any way. If it's in your list, and you missed it, then you missed it and will be sued for missing it. If it's not in your list, and you missed it, then you missed it and will be sued for missing it. It's not the listing that matters: it's the diagnosing that matters. If you miss it, you miss it... regardless of if you list it or not.

To be clear, I am talking about the laundry list style of D/Dx. I *DO* discuss specific diagnoses that I really am considering and then talk about why I don't think it is that: "This is unlikely to be PE because..." This is what many members above have stated, and I agree with that approach. But, what I am against is the laundry list...

Plus, the laundry list is time-consuming and painful, unless you use preset ones, which I don't think protects you in any way for the reason I stated above.

In any case, I tend to write very robotic/mechanistic notes now, like this:

"25 year old male patient who came to us with RLQ abdominal pain. Vital signs reveal fever and mild tachycardia. Physical exam is concerning for RLQ tenderness. Labs show elevation in white count. CT scan negative for appendicitis, but the patient will be hospitalized for serial abdominal exams and close observation."

I just state what I ordered and did. Shrug.

 

[namethatsmell]

In any case, I tend to write very robotic/mechanistic notes now, like this:

"25 year old male patient who came to us with RLQ abdominal pain. Vital signs reveal fever and mild tachycardia. Physical exam is concerning for RLQ tenderness. Labs show elevation in white count. CT scan negative for appendicitis, but the patient will be hospitalized for serial abdominal exams and close observation."

I just state what I ordered and did. Shrug.

I've started writing my notes more like this too, it allows a thought process to emerge without nailing you down to just one or two ddx and seems to defend somewhat from Monday morning quarter backing.

It's like saying everything out loud you're thinking about during oral boards, having too many thoughts can burn you.

 

[Jackson18]

I list my differential because it's an easy thing coders can use to code up to a level 5 chart. The MDM is one of the most frequent areas of the chart where there's not enough info for the coders to get the points they need to code a level 5. A differential is a quick way for them to grab some of these points.
That being said i tend to put in benign things like GERD, IBS, Tension headache etc to get my 4 point differential. Then in the rest of my MDM i discuss the things i'm worried about - ACS, SBO, SAH. No point wasting time saying why you don't think it's all the things in your differential. Most chief complaints really only have 2 or so life threatening things you want to discuss- eg with an HA i'm saying why its not SAH and meningitis. N/V/D why it's not an SBO. Chest pain is the exceptino to that

 

[BAM!]

Personally, I don't feel listing something in a D/Dx protects you in any way. If it's in your list, and you missed it, then you missed it and will be sued for missing it. If it's not in your list, and you missed it, then you missed it and will be sued for missing it. It's not the listing that matters: it's the diagnosing that matters. If you miss it, you miss it... regardless of if you list it or not.

Here's why I think it can help:

You wrote it in your laundry list DDx and missed it. You get sued. At least you can say, "I thought about the correct diagnosis. The diagnosis was missed because the presentation was so unusual and atypical. I met standard of care. There is no negligence."

OR

You didn't write the correct ddx in your list and you get sued. The lawyer notes, "You didn't even consider the correct diagnosis, as evidenced by your documentation. You're a negligent doctor because you didn't even think about the right diagnosis." In this scenario, you have to try to convince them, "But I always think about xyz!! Really, I do. Please believe me!"

Either way is a tough path, but I'd rather be in the first scenario.

Sure the laundry list ddx looks dumb. But who really reads these notes anyway!? 😉 . Also, you don't need to make it 30 items long. But taylor a bunch of bread and butter deadly illness presets to common CC's, and it may even help you review your ddx while writing your MDM.

 

[southerndoc]

All patients get a differential. It helps you legally as well as with billing. It helps to justify a level 5 if you're billing at it.

Clearly explain why you don't think it's something. For instance, not every chest pain gets an aortic dissection workup. I note that "patient's signs/symptoms are not suggestive of aortic dissection." That's all you have to do. Doing expert witness review and peer review for our state medical board, I can tell you that somebody who documents they thought of something and it ended up being that, they have more defense because they considered it than not noting it (which draws the insinuation that they are incompetent and didn't consider it).

Likewise, if you are delayed in calling a consultant for some reason, document it. For instance, I was delayed in notifying neurosurgery for a head bleed. I documented "delay in consulting neurosurgery due to being involved with a trauma activation."

Despite what you might think, lawyers are human. The expert witnesses they hire are also practicing emergency physicians. Sure, you can always find somebody willing to say something for the right price, but it's unlikely to happen (or more difficult for them to find an expert witness) if you justify your actions.

One of the best things you can document is why you were delayed in seeing a patient if they have a bad outcome. "Delay in initial assessment of patient due to surge volume," "delay in initial assessment of this patient due to being tied up with another critical patient and no other physician available to see the patient." Greg Henry got me on this bandwagon.

 

[BAM!]

Likewise, if you are delayed in calling a consultant for some reason, document it. For instance, I was delayed in notifying neurosurgery for a head bleed. I documented "delay in consulting neurosurgery due to being involved with a trauma activation."

Despite what you might think, lawyers are human. The expert witnesses they hire are also practicing emergency physicians. Sure, you can always find somebody willing to say something for the right price, but it's unlikely to happen (or more difficult for them to find an expert witness) if you justify your actions.

One of the best things you can document is why you were delayed in seeing a patient if they have a bad outcome. "Delay in initial assessment of patient due to surge volume," "delay in initial assessment of this patient due to being tied up with another critical patient and no other physician available to see the patient." Greg Henry got me on this bandwagon.

Do you think this is helpful? Are you able to give some real life scenarios where you have seen this type of documentation as beneficial to the ED physician? How long of a delay are we talking? 1 hour? 2 hours? More? I feel hesitant to admit delays on my chart, because it makes it look like I am not triaging correctly.

Also, what if your CT is backed up. Is it enough to say things like, "...delay because awaiting head CT..." Or do you have to actively advocate for your patient to skip to the head of the line?

Soooo if there's a delay, and this delay contributed to a bad outcome, who is responsible? I always imagined it was the physician, because, well, everything seems to shift onto his shoulders... But perhaps it's more the hospital's responsibility for not staffing adequately during a time of surge?

Sometimes I document a timestamp which I "encouraged nursing staff to expedite labs/UA/imaging/workup" etc. But I feel this is somewhat passive aggressive and I not sure how much this helps.

 

[exsanguination]

Do you think this is helpful? Are you able to give some real life scenarios where you have seen this type of documentation as beneficial to the ED physician? How long of a delay are we talking? 1 hour? 2 hours? More? I feel hesitant to admit delays on my chart, because it makes it look like I am not triaging correctly.

Also, what if your CT is backed up. Is it enough to say things like, "...delay because awaiting head CT..." Or do you have to actively advocate for your patient to skip to the head of the line?

Soooo if there's a delay, and this delay contributed to a bad outcome, who is responsible? I always imagined it was the physician, because, well, everything seems to shift onto his shoulders... But perhaps it's more the hospital's responsibility for not staffing adequately during a time of surge?

Sometimes I document a timestamp which I "encouraged nursing staff to expedite labs/UA/imaging/workup" etc. But I feel this is somewhat passive aggressive and I not sure how much this helps.

I am also wondering about hospital-related systems issues and how to document delays to protect ourselves medicolegally

Delay in getting CT scans, lab downtime, taking forever to report critical values because they were "diluting them" or retesting to confirm elevated values, admit holds, pharmacists with draconian medication policies.

Do any of you address these in your notes? Does it just look like an excuse and an attempt to displace responsibility?

 

[BAM!]

Do any of you address these in your notes? Does it just look like an excuse and an attempt to displace responsibility?

Maybe it's not so bad to displace responsibility... Goodness knows hospitals have been doing to doctors for years.

 

[turkeyjerky]

Maybe it's not so bad to displace responsibility... Goodness knows hospitals have been doing to doctors for years.

But doesn't this just lead to an outcome where everyone goes down together?

 

[deleted109597]

But doesn't this just lead to an outcome where everyone goes down together?

If hospitals start being held responsible for the things they control as opposed to it always being our fault. Maybe they could start fixing them.
Sort of like how OSHA has fined hospitals for staff getting assaulted. Because heaven knows the hospital gives no ****s about that. But when they start risking punishment, maybe they'll fix the problem.
Think of it like the EPA.

 

[BAM!]

But doesn't this just lead to an outcome where everyone goes down together?

...isn't that what we do already every time we consult others to "spread the wealth/liability". It's rooted in our blood.

Besides, the hospital has bigger pockets than my medmal limits.

 

[southerndoc]

I can absolutely 100% say that comments a physician made in his note caused a delay in seeing a patient because of a surge in volume kept him from getting sued. I'm sorry that I cannot discuss specifics as the case is still ongoing against the hospital, but I will say that it led to subpoenas of hospital staffing, CT times, etc. and the hospital is in litigation and the emergency physician is not.

You are correct in that the hospitals will throw you under a bus. You should protect yourself. If a patient has a bad outcome because the ER is short 20 nurses and a CT tech, then why should it be your responsibility as they aren't your staff?

 

[BAM!]

I can absolutely 100% say that comments a physician made in his note caused a delay in seeing a patient because of a surge in volume kept him from getting sued. I'm sorry that I cannot discuss specifics as the case is still ongoing against the hospital, but I will say that it led to subpoenas of hospital staffing, CT times, etc. and the hospital is in litigation and the emergency physician is not.

You are correct in that the hospitals will throw you under a bus. You should protect yourself. If a patient has a bad outcome because the ER is short 20 nurses and a CT tech, then why should it be your responsibility as they aren't your staff?

Did that documentation then jeopardize the ED Doc's / Group's relationship with the hospital? (not that you shouldn't protect yourself)