Patient instructions

[doctalaughs]

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I'm in an outpatient specialty but you guys seem to be the masters of good d/c instructions. How much do you think these really help you legally? If a patient totally blows off the instructions (say for a follow up visit to recheck on symptoms, or ignores signs clearly in the instructions) and has a bad outcome does this really make a defense or dismissal of suit much easier?


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[da8s0859q]

I'm in an outpatient specialty but you guys seem to be the masters of good d/c instructions. How much do you think these really help you legally? If a patient totally blows off the instructions (say for a follow up visit to recheck on symptoms, or ignores signs clearly in the instructions) and has a bad outcome does this really make a defense or dismissal of suit much easier?


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My $0.02: I consider good discharge instructions, particularly good ED return precautions, to be lumped in with "standard of care" in my head. If I send home a young person with a potential appendicitis because someone doesn't want a CT, doesn't want overnight observation or whatever, and they end up with an appy a day later, it needs to be clear in my note that we talked about this, and clear on paperwork that you need to get back here in 12-24 hours for repeat evaluation because this is still possible.

This has come up for me before in one way or another. Not legal, but patient complaints where I just pointed at my discharge paperwork in response along with my note detailing that we talked about this.

I do feel it is somewhat protective -- the degree to which depends on the case.

 

[Zebra Hunter]

I've been told by my med mal friends to keep it vague, as it is easier to defend vague than overly specific. It's fine to give them exact things to look for, but should always include "return for any other concerning issues". Personally, I don't include the specifics in my note or written instructions because from I've been told, writing down that you have given return precautions for appendicitis and it turns out to be something else just demonstrates that you were operating with a limited differential. I usually give specific verbal return precautions, then write in my note "Discussed differential with pt, gave specific signs and symptoms that would require immediate return. Strongly advised pt to return for worsening/non-improving symptoms or any other concerning issues, otherwise, follow up in 1-2 days with PCP (or specialist) for reevaluation. Pt voiced understanding of reasons to return and is agreeable with discharge." Then in the discharge instructions I just reword that.

 

[da8s0859q]

I've been told by my med mal friends to keep it vague, as it is easier to defend vague than overly specific. It's fine to give them exact things to look for, but should always include "return for any other concerning issues". Personally, I don't include the specifics in my note or written instructions because from I've been told, writing down that you have given return precautions for appendicitis and it turns out to be something else just demonstrates that you were operating with a limited differential. I usually give specific verbal return precautions, then write in my note "Discussed differential with pt, gave specific signs and symptoms that would require immediate return. Strongly advised pt to return for worsening/non-improving symptoms or any other concerning issues, otherwise, follow up in 1-2 days with PCP (or specialist) for reevaluation. Pt voiced understanding of reasons to return and is agreeable with discharge." Then in the discharge instructions I just reword that.

This also. Was just using the appy as an example. I do the above as well, and I always include reinforcement to come right back for any ongoing/worsening anything.

Not saying it's the perfect way to do it, just that I feel it's a solid way to do it.

 

[JustPlainBill]

Outpatient FM here but -- I tend to include "AE/SE of medications discussed, warnings given, patient voiced understanding and acceptance. "

Now, if there's anyone in the room I state it something like this: "Patient and adult female companion who was present during entire visit voiced understanding and acceptance."

Had a residency lawyer who lectured to us one year during our retreat state that it would be helpful to have a record of whoever was in the room and for how long -- but I don't name names, etc. I also include any observations of behavior with children -- i.e. patient observed to be seated comfortably on the exam table, in no acute distress, speaking in full sentences and appropriately playful and interactive -- that saved me from a patient complaint during residency.....

 

[Apollyon]

"Good discharge instructions are better than an accurate diagnosis". It's hard to fight "if you have nausea or vomiting, if you are worse in ANY way, or you think you need to be seen again". "Mr. Smith, were you worse? Yes? Why did you not come back, as instructed?" "Mr. Jones, did you think you need to be seen again? Why weren't you? You we instructed to do that, correct?"

 

[TrumpetDoc]

Told by a med mal lawyer during a talk many years ago that documenting "verbally discussed ..." and "pt (and family too even better) verbalized understanding of our discussion/plan/in lay terms" is extremely helpful. I've used this ever since. Have a nice macro on Dragon for it...of course I also actually do it and always ask if any Qs.

 

[NYEMMED]

Told by a med mal lawyer during a talk many years ago that documenting "verbally discussed ..." and "pt (and family too even better) verbalized understanding of our discussion/plan/in lay terms" is extremely helpful. I've used this ever since. Have a nice macro on Dragon for it...of course I also actually do it and always ask if any Qs.

This is correct and very helpful to document.

There was a EMRAP on D/C instructions a few months ago.

Basically documenting the verbal discussion is key.
Anything written in the discharge instructions are not the patients responsibility to read per previous cases.

 

[da8s0859q]

Anything written in the discharge instructions are not the patients responsibility to read per previous cases.

Elaborate?

 

[doctalaughs]

So is it also helpful to list an exhaustive differential diagnosis? Ive seen docs do this to the point of looking silly (ie they must have a dot phrase for a list of 100 causes abdominal pain). Is it really in your advantage legally if the final diagnosis was in your ddx just to show you might have considered it?


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[NYEMMED]

Elaborate?

Several cases with judgement against physicians won due to the decision that patients are not required to read or understand anything written in your discharge packet to them.

Also telling a patient to return for worsening or concerning symptoms - several cases won against physicians because a patient is not "medically trained" to understand when they are worse or what is worrisome, unless the physician wrote they instructed the patient to return for "state specifics here"

 

[Zebra Hunter]

Also telling a patient to return for worsening or concerning symptoms - several cases won against physicians because a patient is not "medically trained" to understand when they are worse or what is worrisome, unless the physician wrote they instructed the patient to return for "state specifics here"

I highly doubt those cases were lost due solely to not being specific with symptoms in d/c instructions. Nevertheless, several cases have gone against physicians who are overly specific, as well. They state as much in the EMRAP segment you cite. In fact, they recommend against overly specific lists of symptoms to return for, and it sounds like the case you are citing is the one from the EMRAP segment, in which the patient was actually given an exhaustive list of symptoms to return for, as well as, worsening or concerning issues and still lost the case. What they actually recommend you write in your d/c instructions in that segment is "Please return immediately if you get worse, you don’t get better or you develop any new or concerning symptoms." With emphasis on keeping your instructions open ended with regard to return precautions. Where they do recommend you get specific is with time of follow up and who to follow up with. No method is going to be 100% effective in warding off lawyers; however, if I was the defendant's attorney, I'd prefer the discharge instructions that gives me more wiggle-room to argue with.

Also, do you mind providing a source for your statement that "Anything written in the discharge instructions are not the patients responsibility to read per previous cases." As I have heard completely the opposite, with many physicians having been saved by their personally written discharge instructions (not that patient education stuff).

 

[Janders]

I tend to shoot for the middle, and list (roughly) 3 specific worrisome symptoms I am concerned about, along with the generic "come back if you are sick!!!"

i.e. For a UTI who is discharged--

PLEASE TAKE ALL YOUR PRESCRIBED MEDICATION/ANTIBIOTIC!!!!
Please drink plenty of fluid
You can use TYLENOL for pain as needed

As we discussed, please return if you have WORSENING PAIN (Especially in the back), VOMITING, or HIGH FEVERS. Come back immediately if you have any severe or serious new symptoms/concerns. Otherwise please see your PCP in the next 1-2 days.

*attach generic UTI instruction sheet*

(The RNs get I kick out of my use of caps and exclamation marks. In our system they are instructed to read over any specific instructions I list with the patient who then voices understand. RN documents this in their note, which adds more protection than just MY note about instructions. They love to show the patient "see, the doctor thinks its really important you take your medicine, he put 4 exclamation marks!!!!")

 

[Apollyon]

I tend to shoot for the middle, and list (roughly) 3 specific worrisome symptoms I am concerned about, along with the generic "come back if you are sick!!!"

i.e. For a UTI who is discharged--

PLEASE TAKE ALL YOUR PRESCRIBED MEDICATION/ANTIBIOTIC!!!!
Please drink plenty of fluid
You can use TYLENOL for pain as needed

As we discussed, please return if you have WORSENING PAIN (Especially in the back), VOMITING, or HIGH FEVERS. Come back immediately if you have any severe or serious new symptoms/concerns. Otherwise please see your PCP in the next 1-2 days.

*attach generic UTI instruction sheet*

(The RNs get I kick out of my use of caps and exclamation marks. In our system they are instructed to read over any specific instructions I list with the patient who then voices understand. RN documents this in their note, which adds more protection than just MY note about instructions. They love to show the patient "see, the doctor thinks its really important you take your medicine, he put 4 exclamation marks!!!!")

My staff use a yellow highlighter to go over my things, although the first line for those who get abx is "Take ALL ANTIBIOTICS until they are ALL GONE!" That is as sensationalistic as I get.

 

[deleted109597]

I tend to shoot for the middle, and list (roughly) 3 specific worrisome symptoms I am concerned about, along with the generic "come back if you are sick!!!"

Same. Although I type "or any other concerns", and start with "as we discussed".
But I also practice in Texas, so I could probably include "Don't be a *******" and still be ok.

 

[heroesinahalfshell]

Has anyone heard anything in regards to how well AMA (against medical advice) documents that you have pts sign holds up legally? I feel that sometimes if I have high concern for there being something wrong and the pt is refusing treatment/admission, etc. or if I feel that the pt has been very upset or "appears" litigenous and is refusing something I will have them sign an AMA. Otherwise I just document in my chart that "testing/treatment/observation/admission/etc." was refused by pt, pt mentating appropriately, has rational thought, etc etc. Is that sufficient?

 

[deleted109597]

AMA forms are worthless. This has been discussed. They mean nothing.

 

[sum dude]

Several cases with judgement against physicians won due to the decision that patients are not required to read or understand anything written in your discharge packet to them.

Also telling a patient to return for worsening or concerning symptoms - several cases won against physicians because a patient is not "medically trained" to understand when they are worse or what is worrisome, unless the physician wrote they instructed the patient to return for "state specifics here"

Our group lawyer advised us to write as much as possible, and the more d/c instructions you have, the better. Especially if the patient doesn't see anyone in like 4 weeks (common)--usually the last doctor seen holds hot potato. It's better to say "here in your d/c instructions it says to return to ED or your doctor if you have worse pain, fevers with pain, pass out, chest pain, or concerning/worsening symptoms"