By Stacey Kusterbeck
ED patients do not always take medications as directed. Sometimes, they do not fill prescriptions at all. “There may be a lack of understanding of why the medication is necessary, financial and economic concerns, lack of clear discharge instructions, or no primary care follow-up,” says Susan Paparella, MSN, RN, vice president of services at the Institute for Safe Medication Practices.
ED staff are responsible for explaining the discharge treatment plan to the patient, allowing them time to ask questions, and providing a written explanation of all new medications (preferably in the patient’s native language and at an appropriate reading level). “The teach-back method should be used for complex medication issues or treatment plans,” Paparella adds.
For example, if the department is discharging a patient on a metered-dose inhaler, and the patient has never used one before, a demonstration of the device and evaluation of safe administrative technique is warranted.
However, emergency care providers might suspect the patient is unlikely to follow the instructions provided, for whatever reason. If it seems as though the patient does not understand, Paparella says staff should try to provide the information to a family member or caregiver who may be with the patient or can be reached by phone. “ED staff dealing with an episodic visit for a particular issue may not fully appreciate the psychosocial needs or financial concerns of the patient,” Paparella explains.
Complex psychosocial issues may be interfering with the patient’s ability to adhere to the treatment plan. Paparella suggests clinicians involve social services, who can intervene and assist. “This plan may involve home care support, if that is deemed to be appropriate,” Paparella offers.
Noncompliance with discharge instructions can result in bad outcomes for the patient. It also can trigger malpractice claims. “In any game of ‘Who said what?’ the strongest evidence is going to be a well-written, credible, contemporaneous chart note,” says Michael S. Victoroff, MD, risk management consultant at COPIC, a Denver-based medical liability insurance provider.
Asking the patient to sign the discharge instructions is not sufficient. “Simply having someone’s signature on a form is pretty weak,” Victoroff says. “If there’s a dispute, it’s customized, thoughtful discussion that’s going to prove you did what was needed.” Victoroff offers some practices to help emergency care providers defend themselves legally in these malpractice cases:
• Ensure the discharge plan is complete, understandable, and achievable. “Your instructions may be reviewed by a lay jury,” Victoroff notes.
A statement such as, “Return if you have any concerns” is not specific enough. “It only opens up the question: What should the patient be looking for?” Victoroff says.
Victoroff says that to be legally protective, documentation needs to be specific. For instance, clinicians might chart: “Call us if you aren’t able to do something on our list of instructions,” or “Return if the feeling in your fingers isn’t back after three hours.”
• Comment on any barriers to complying with the discharge plan. Patients may report financial, mobility, communication, or environmental factors that make it difficult to follow the treatment plan. If the patient’s mental capacity or language proficiency are at issue, the medical record should reflect what was done about it.
For example, if providers cannot speak the patient’s primary language, the chart should describe how the discharge process was completed. Similarly, if the patient is living with a cognitive impairment, the chart should recount how staff assessed the patient’s ability to comply with the discharge plan.
“If the patient explicitly rejects a recommendation, you should note that, and try to describe their reasons,” Victoroff says.
If there are barriers to compliance noted in the chart, the emergency physician should note how these were addressed. Victoroff gives these examples of good documentation:
• “The translator assisted during the exam and discharge process.”
• “The family assured us someone would be present to supervise the patient continuously for the next 24 hours.”
• “Because of the patient’s balance problem, she was provided with a walker, a ‘road test’ was done to confirm she could use it, and the home safety plan was fully discussed with her daughter, who lives with her.”
Social determinants of health are important to capture in the medical record, even if they are noted in a cursory fashion. “The days of ‘streeting’ the patient with $5 for a bus ticket are long past,” Victoroff observes.
There are limits to the ED’s ability to address many social realities. Few departments can provide shelter, meals, or legal advice. “But this is a failing of our system,” Victoroff asserts.
Emergency care providers may not be able to solve the entire problem, but they can refer patients to resources in the hospital or community. Those efforts should be documented in the medical record. Staff might document: “Social services referral for Medicaid application,” “Referred to local Legal Aid,” or “Substance abuse agency referral.”
“The ED provider should acknowledge obvious barriers to care, and describe steps taken to address them,” Victoroff says.
The key lies in ensuring the discharge plan is complete, understandable, and achievable.
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