Pertinent negatives?

[Lecithin5]

Do any of you go out of your way to routinely document pertinent negatives on your preop H and Ps on all patients? Such as ‘denies chest pain, SOB’ etc? If so, which do you think are the most important pertinent negatives do you document (other than the obvious chest pain or shortness of breath etc). Because depending on the type of template that one uses, perhaps there is a difference (from a litigation standpoint?) between simply checking off ‘negative’ under the whole body system section versus individually checking off each question within the section versus leaving the section blank (?).

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[Aether2000]

Yes. I have configured my template on Cerner intentionally to be blank, and spend 5-10 minutes per patient documenting the negatives one by one, and expanding with text on the positives. It takes longer, but it is surprising how much information pulled from other sources to the chart is incorrect.

 

[ZzzPlz]

Any time I use LMAs I document no nausea, no Gerd, npo.

Same with any GETA case that I don’t think needs RSI that could be questioned later, such as hernias and other abdominal issues with no signs/symptoms of bowel obstruction

 

[Noyac]

Does anyone think these matter?

 

[nimbus]

Besides npo status and allergies, I only document pertinent positives. My preop notes are very short.

 

[ZzzPlz]

Does anyone think these matter?

Regarding my response above, yes I do.

I’d feel better if someone aspirated with an LMA and I had asked and documented the above.

Would it prevent a lawsuit if the patient was set on it? Probably not. But it may decrease the settlement or be enough ammunition to try and fight the case. I’ve never had to deal with that though so maybe I’m being naive.




OP—I also document patient’s loose or rotten teeth. I’ve had people threaten legal action when I should be billing them for extractions

 

[Noyac]

Regarding my response above, yes I do.

I’d feel better if someone aspirated with an LMA and I had asked and documented the above.

Would it prevent a lawsuit if the patient was set on it? Probably not. But it may decrease the settlement or be enough ammunition to try and fight the case. I’ve never had to deal with that though so maybe I’m being naive.




OP—I also document patient’s loose or rotten teeth. I’ve had people threaten legal action when I should be billing them for extractions

I disagree, it won’t prevent or protect you from a law suit.
I wouldn’t feel better if I had charted the “negative” and they aspirated with an LMA. I always ask, I just don’t necessarily chart the negatives. It does nothing IMO.

 

[Aether2000]

In legal circles, if it is not documented, it wasn't done. If your chart gives options of listing positives, negatives, and not answered, those questions without answers will be deemed not to have been asked, leaving you with a very short history and physical. This short H and P will be attacked in court as inadequate. Have seen it several times before in court. Not documented=not performed

 

[Lecithin5]

I disagree, it won’t prevent or protect you from a law suit.
I wouldn’t feel better if I had charted the “negative” and they aspirated with an LMA. I always ask, I just don’t necessarily chart the negatives. It does nothing IMO.

I guess this is the important question that I (and I’m sure many of us) have: I hear both sides of the equation-what algosdoc says (ie if not documented, it didn’t happen) and what noyac and others say (ie won’t protect you in a court of law). Which is it? Does anybody have any sort of expertise on this? Any law experts that can weigh in? What is the “sweet spot” for documentation- not too much superfluous documentation but also not too bare-bones? I recognize these are broad questions...

 

[deleted171991]

Just be careful with templates when documenting. If the template describes even one thing that did not actually happen, it may make the court question all of it.

 

[Aether2000]

I agree with Noyac... it will not prevent litigation since those who feel jaded will sue for any reason. However it may help mitigate the response to such litigation in court and even more importantly in arbitration or in pointing the finger of fault away from yourself