Welcome to Talk EM, brought to you by the Emergency Medicine Institute where our goal is promoting clinical excellence. Our focus is for the advanced emergency medicine practitioners, nurse practitioners and physician assistants who work in the field, taking care of people who are really sick.

I recently got a request to share information about documentation. A student in a board review course was hired in an emergency room. He said, “John, I need some help with documentation. Can you do a podcast on that?” Absolutely.

Let me start by saying that I don’t think I’m awesome at documentation. I want to tell new clinicians right off the get-go that I think I struggle with documentation because of my psychology out of the gate. Twenty-one years ago, when I graduated from PA school, I wanted to be fast and efficient. And I was. To this day, I could clear out a Fast Track faster than most.

I could blow your mind with how fast I could clear out a waiting room, but I sacrificed my documentation. When I worked as a hospitalist and in the ICU, that followed me. I’m really good with a sick patient. Give me someone who is really sick and I’m at my best. But I had some feedback on my documentation; I was told it was an area I could improve upon.

Let’s be really crystal clear about something here: documentation has to do with protecting yourself and getting paid.

Documenting to Get Paid

Getting paid has to do with optimal documentation for billing. I cannot really speak to that, nor do I even want to. You have to learn how to document for the appropriate reimbursement. If not, you’re not going to make money for your hospital system or employer. Therefore, you don’t have the optimal value. You won’t get your raises, and you can’t blame anybody.

If I owned a popsicle stand and you sold popsicles but you weren’t making me as much money as you should be, I’d have a tough time keeping you employed.

You have to take on the responsibility of learning how to properly document HPI, past family history and medical history to get optimally reimbursed. This is also the responsibility of your employer. They should be closely watching and policing your documentation. If they’re not, it says something about the leadership.

Documenting to Protect Yourself

I want to talk to you about documenting to capture required information, but more importantly, how to keep yourself out of trouble.

I work in medical malpractice defense and do a lot of teaching on medical malpractice. In fact, we recently had a defense attorney speak at one of our emergency medicine conferences. They did a mock deposition of an audience member and talked about how they think about a chart review. There was also a plaintiff attorney who talked about what they look for in malpractice cases because those are the cases that the plaintiff wins.

The documentation in your chart is very important, not just to communicate information to other providers, but to protect yourself. When a lawsuit occurs, it comes in one of five different trigger points, or stages. If any one of these trigger points is interrupted, there’s no lawsuit.

  1. You see patients. If you stop seeing patients, you won’t get sued. Some people go into academia, saying they don’t want to see patients anymore. They’re burned out. If you’re like most people, that’s not really an option, so you’re going to see patients.
  2. Something bad happens. You keep educating yourself to prevent a bad outcome. That’s why you go to CME conferences. It’s called the practice of medicine because we’re always improving, always trying to get better at what we do.
  3. The patient gets angry and seeks an attorney.
  4. At the very least, the attorney takes a look at the case.
  5. The attorney agrees the patient has a good case and you get a certified letter. After an angry patient sees an attorney, the attorney says, “I want to take a look.” The attorney thinks this is a good case they can get paid on, so the attorney says, “Yes, I want to proceed.”

The bottom line is you can’t stop seeing patients. That’s not reasonable. You can’t control bad outcomes. You might mitigate them, but you can’t control them. Sometimes bad things happen. Patients go to attorneys because they’re really angry. That’s important. If people really like you, you don’t get sued. No one walks into an attorney’s office and says, “Oh, I really loved her and she was so sweet to my mom. She was so kind and I feel horrible, but I want to sue her.”

Nobody does that. That’s not how it goes. Patients get angry; there’s an adverse outcome and that’s the trigger point. First and foremost, if you don’t have good bedside manner, your chances of getting sued go way up. That’s based on Press Ganey data. It’s no joke, but we’re not talking about that today.

The monetary value of the case is what’s going to determine if the attorney gets a request for records. We can’t really control that. If there’s a bad outcome, you can’t control how bad of an outcome it is. I was once sued for a case involving a young boy that came in with right upper quadrant abdominal pain. When all was said and done, he ended up having a tourniqueting rubber band on the shaft of his penis. I was sued for that and it was my second lawsuit.

Eventually, the suit was dropped, but the initial thought was that he may have to have the head of his penis amputated. That would be a really big lawsuit. Juries won’t accept that very well. Fortunately, he didn’t. It reperfused and everything was fine. All of a sudden, the monetary value of the case dropped significantly and the attorney lost interest.

The last trigger area is where the attorney thinks, “This is a good payday. I want to send a certified letter.” This is based on your documentation and whether or not the attorney thinks they can win. When a lawyer reviews a chart, they’re going to have a physician review it as well. The attorney wants the physician to nod their head and say, “I think there’s liability here. I think this is a case you could win.” Now, they have to file what’s called a certificate of merit. That’s based strictly on a physician saying, “Yes, I think there’s a case.”

To a huge degree, the chart is going to say one of two things to the reviewing physician.

  • Negligence: You didn’t even think about it, weigh it out or consider it. The attorney is coming after you hard because that’s how they get paid. Negligence is malpractice. If you don’t think about a problem, you’re negligent.
  • Judgement: If you thought about it, weighed it out, did an appropriate workup and made appropriate thought processes along the way, that’s not malpractice. Despite your best intentions, things went differently and there was a bad outcome. That’s not negligence, it’s just judgment. Judgment is very defendable.

Remember, you have defense attorneys and plaintiff attorneys. Defense attorneys defend us; plaintiff attorneys come after us. Plaintiff attorneys find lawsuits very risky because once they send out deposition requests and certified letters, it’s on. They put a huge bet on the pass line at the craps table and they won’t take it lightly.

If a plaintiff attorney doesn’t think they’re going to win, they’re not going to put a bunch of people through depositions. That’s very expensive for them. So if they come after you, it’s because they believe they have a good chance they’re going to win.

A couple of years ago, I spoke with a local plaintiff attorney here in Buffalo as I prepared for a medical malpractice lecture. I found him a very honorable man and I liked him a lot. He said to me, “John, I’ve been doing it for 28 years. Thousands of cases I’ve had in front of me and the insignificant cases, I don’t take those. I don’t want anything to do with a bad case. But if I take one of the cases, you should be in trouble, because there’s an apparent problem and I’m coming after you very aggressively.”

Oftentimes in medicine, we think of plaintiff attorneys as the enemy. It was important for me to hear that they don’t take cases lightly. The biggest thing I want to tell you about documentation is to think about high-risk scenarios every time and document accordingly. You have to be a documentation alarmist. If you’re not, you will get burned. Think to yourself, “What’s the worst-case scenario? Did I document accordingly?”

When a kid comes in with a viral syndrome, you have to assume in two days he’s going to have bacterial meningitis. Did you document accordingly? Every single person with a cough has a PE. Did you document accordingly? I talked to an attorney here in Buffalo because I got into a debate with a third-year resident about documenting the PERC rules with an asthma patient. Remember, PERC is pulmonary embolism rule out criteria. So the student says to me, “I wouldn’t document that, it’s not necessary because it’s asthma.” I wonder, “Is he right?”

I called Sally Broad, a local defense attorney. I asked her, “Someone comes in and they look like classic asthma but two days later they die of a PE. What do I need written on the chart to defend myself?” She tells me, “I need to know you thought about it.” It comes down to negligence versus judgment.

That doesn’t mean you run a CAT scan, it doesn’t mean you run D-dimers. It means that in your chart you put pertinent negatives and positives to communicate to everybody that you thought about it. No recent travel, no hormone replacement, no birth control pills, no family history of blood clots, no hemoptysis, no pleuritic chest pain. All you have to do is document your key pertinent negatives and positives.

Learning to Document

You need to know what the really high-risk scenarios are. I did a talk that combined medical malpractice defense with Sun Tzu’s ancient secrets of strategy from The Art of War to help us think about how to proactively defend ourselves. Think about the high-risk scenarios that you have to document accordingly for.

Head to Toe

Understand subarachnoid is lethal. You better not miss it; you need to document accordingly. What are the hot buttons for subarachnoid hemorrhage? In my mind, every single headache is a subarachnoid hemorrhage, temporal arteritis or meningitis until proven otherwise and I will document it that way. You can’t miss them.

You have to be very sensitive to vision-threatening injuries. Document visual acuity and the limbus. Look at the head and face. Think about peritonsillar abscess and Ludwig’s angina. You have to be very concerned about dental pain. Is it really dental pain or could it be an anginal equivalent? Think, “Boy, diabetics are always very, very, very sneaky.”

When it comes to the chest, there are five causes of chest pain. Remember them using the mnemonic “Who’s Your PAPPA?” It’s pericarditis, acute coronary syndrome, pneumothorax, pulmonary embolism and aneurysm thoracic dissection. I believe pulmonary embolism is the grim reaper of chest pain and shortness of breath. It is incredibly sneaky. You have to rule out PE and acute coronary syndrome. This is especially true for newer emergency medicine practitioners because you can easily be blinded by a bias to benign. You see so many things that are benign, you start thinking everything is benign and you miss something. For anybody with pulmonary symptoms or a cough, use the mnemonic HORID. Is it their heart, obstruction, reaction, infection or death?

There are lots of bad things that can happen in the belly. You have to know how to do a really good physical exam and document accordingly. I consider an ectopic pregnancy the most lethal. I don’t like to walk into the room of a woman of childbearing age unless I know if she’s pregnant or not. That’s very important to me. In cases of testicular torsion, time is of the essence.

You have to document in detail what you’re thinking and rule out worst-case scenarios. The most important way to document this is in your differential diagnosis. In your medical decision making, you have to tell me all the things you’re thinking about and how you ruled them out.

Thinking Differently

When I started teaching emergency medicine, I wanted to teach usable medicine. There are a lot of conferences that teach good stuff, but they don’t change your practice. I aim to teach measurably useful medicine that changes your practice.

Over the years, we’ve gotten feedback saying we change how providers think. Our courses teach you to think in terms of the worst-case scenario. That’s the first thing you learn when you work on an ambulance. It’s scene safety. When you get to the scene of a car accident, you don’t rush up to the car to help the patient. You make sure you don’t get hit by a car too because the worst-case scenario is not that the patient dies in the car accident. The worst-case scenario is that you stop to help them and you get killed as well.

Practicing medicine as an advanced practitioner is the same thing. You have to protect yourself medically legally. After you get a couple lawsuits under your belt, you might not be employable. You may not be insurable or worse, you’re devastated by a lawsuit and it makes you a paranoid practitioner. The only way to protect yourself against a lawsuit is to be proactive about your documentation.

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