Does your documentation satisfy irate colleagues?
When a general surgeon with a reputation for being aggressive and hotheaded came down to the emergency department (ED) at North Shore, he furiously complained about a patient in his care.
"The patient was seen in our ED one month prior for abdominal pain," recalls Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. "He was found to have a large gallstone, with the rest of the gallbladder examination being normal."
The patient improved during his course in the ED and preferred to be discharged so he could see his own surgeon at a different hospital, adds Blaivas. Three weeks later, the patient had surgery that did not find a gallstone, but he later returned to the ED with fever and abdominal pain. "On abdominal CT, an abscess was found by the patient’s liver," says Blaivas.
The surgeon claimed that the ED had incorrectly diagnosed a gallstone and also missed the previous liver abscess. "Luckily, I had a copy of our formal report with pictures which clearly showed a large gallstone in the neck of the gallbladder with the rest of the gallbladder being normal," says Blaivas.
Blaivas informed the surgeon that the ED does not check the entire liver on a gallbladder scan. He adds, "In any case, it was obvious from clinical history, my ultrasound, and current findings that the stone was dropped into the abdomen accidentally, as can happen during the operation, and was missed."
As a result, the patient now was back with an abscess, explained Blaivas. "The surgeon who originally promised a full investigation and said he would make sure we did not scan again was never heard from again on this topic," he reports. "It is hard to deny well-documented evidence when you hold a copy in your hand." Poor documentation makes you look like a "fly-by-night" operation, he warns.
Here are effective ways to document your ultrasound exams:
• Every exam must be documented. This documentation should include written or dictated notes and key images attached to the chart, according to Robert Jones, DO, RDMS, FACEP, assistant professor of emergency medicine at Case Western University, and faculty of the emergency medicine residency program at MetroHealth Medical Center, both in Cleveland. "Some physicians feel that they can unofficially’ do the ultrasound and not record it," he says. "This is a big mistake."
For example, some clinicians think that if they don’t see an abdominal aortic aneurysm (AAA) they can just move to other diagnoses without documenting the exam, says Jones. "Unfortunately, patients will most likely remember that the ultrasound was done and mention it to consultants or their doctor," he says. "There will be no respect for ED ultrasound if it is a hidden exam."
Blaivas points to the following scenario: An 80-year-old patient comes in with abdominal pain, and there is concern about an AAA, so an ultrasound of the aorta is performed. The test is negative, but a month later the patient goes to their private physician and asks for a report saying the aorta is normal caliber and the patient in not in danger from it. The radiology department has no record of the exam. The private physician then spends half a day making calls about the ultrasound and suggests to the patient he is mistaken. "Eventually the ED is called, the patient’s chart is pulled, but no record of the normal scan exists, and everything has to be repeated. This sounds comical, but I have seen this happen over and over," says Blaivas.
Radiologists often complain that EDs are not documenting properly, says Blaivas. "This seems to be one of the last tactics left to the radiologists that would like to see ED ultrasound squashed," he says. "Administrators know that poor record keeping is dangerous and looks bad."
Armed with good documentation, Blaivas has headed off several radiology complaints, he says. When Blaivas performs an exam, he generates a formal report and hard copy images, stapled to his billing/report sheet. "A copy goes into my file for future reference and a copy, plus the original goes into the medical record," he says.
• Use templates. Jones uses templates for various "limited" ultrasounds, which allow him to use checkboxes or hand write information. Pertinent images are affixed to the back of the sheet and become part of the permanent medical record. (See Ultrasound Examination List Template: Click here.)
He also comments on the ultrasound’s impact on clinical management so other physicians can understand his goals. Jones gives the following example: "A limited transabdominal/transvaginal ultrasound was performed to verify the presence of an intrauterine pregnancy. This exam was not performed to identify all sonographically detectable pathology, and the patient was made aware of this. The findings of the study include a single viable intrauterine pregnancy. There was a minimal amount of free fluid in the cul-de-sac."
• Document success stories. It’s especially important to document any instance when the ED’s use of ultrasound saved a life or came through when radiology ultrasound failed, suggests Blaivas. "This may seem underhanded, but there will be no punches pulled on you when radiology wants to close you down," he says.
Source
For more information about documentation of ultrasound examinations, contact: Robert Jones, DO, RDMS, FACEP, Department of Emergency Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109. E-mail: [email protected].
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