Learn of problem before chart is done?
A patient presents with a headache and is sent home on medication for migraines, with only the chief complaint documented in the chart. Later that night, the emergency physician calls asking for admit orders, because the patient is being admitted for a brain bleed that the initial treating physician missed.
The physician now knows the bad outcome, and the timing of the note will be memorialized in the chart.
In this situation, a lawsuit is likely, so physicians should consider consulting risk managers, hospital counsel, or even outside counsel, suggests Joseph P. McMenamin, MD, JD, FCLM, a Richmond, VA-based healthcare attorney and former practicing emergency physician. "Do this by telephone, and seek verbal advice from someone experienced in the handling of claims," he says. "That gives the person an opportunity to weigh whether you can make some limited explanation for why you omitted this particular data in the note you wrote initially hours earlier."
There is no general rule for this situation, says McMenamin, "and it is a delicate call. But the basic rules don’t change. You still indicate that your note is late, with a just the facts, ma’am’ approach."
If there are facts that justify the original decision to send the patient home, McMenamin says "there is nothing remotely wrong with making sure such facts are accurately recorded, as long as you make it clear that it’s a late entry."
If a chart is only partially completed and a physician learns of an adverse outcome before going back to finish and finalize the medical record, "that is a bad situation," says John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland. "An attorney will impugn the motivation with respect to completing the chart after the fact."
Tafuri advising clearly documenting what was added late, making certain that it is clearly dated. Be certain that the added documentation is consistent with other contemporaneous prior documentation by nurses and other medical personnel, he adds.
"Recognize that what you add will be looked at very critically, and that improper motivation will be alleged," he says.
As for whether the chart should reflect that the physician knew of the bad outcome before completing the note, Tafuri says this is a tough judgment call.
"It is certainly not inappropriate to do so, but it would be important to be clear and reasonable in what is added," he advises. "Do not document excessively to the known subsequent diagnosis. Otherwise, it would look too self-serving."
