Charting on "ruled out" diagnoses?

[NewtonsApple]

For reference. Recent grad 3 months working first job in EM. Mostly 5-3, occasional 2. 

 

The doc signing my charts the other night asked if I would start listing diagnosis I ruled out by either selecting them in the diagnosis section or typing a little blurb (which he preferred). Considering the same workup is done for a patient, what is the assumed liability for charting "ruled out ___ diagnosis versus only listing present diagnoses?

 

For instance, I had a pt c/o anxiety attack and listed "headache after the episode" as a complaint. my primary dx was anxiety attack with secondary dx of headache, chest discomfort. I worked up the chest pain for MI, PE, etc. (all neg). Per the doc, I need to chart I ruled out Subarachnoid since she had a complaint of headache. While I had no clinical suspicion of a cranial bleed, that doesn't mean I necessarily ruled it out.

 

As a green EM PA, I realize that there are subtleties and outliers of disease and trauma that will take time to pick up on. Should I be stating I ruled something out, especially in the face of no diagnostic workup other then my H&P. Would charting something like, "clinical suspicion for _____ is low due to _____ missing/present in physical exam" be more appropriate than, "ruled out ____." or is it semantics? is there an insurance reimbursement element to listing ruled out dx or mainly liability?

 

How do others approach charting, Thoughts and comments appreciated. 

[EMEDPA]

I list a medical decision making section for my notes that says things like:

"SAH unlikely due to slow onset of h/a over days, many similar prior headaches, no new or worrisome sx, and complete resolution with imitrex. "

 

"PE unlikely given no risk facrtors, stable VS at presenation, and sx resolved with albuterol neb tx"

 

etc.

 

you need to show that you at least considered a serious dx if one is in the ddx.

[cbrsmurf]

Like EMEDPA said.  Goes for all specialties/primary care, not just EM.

[True Anomaly]

Echo what EMEDPA said.  It helps to know what "buzz words" there are that pinpoint a specific diagnosis, such as subarachnoid- "Worst headache of life, sudden onset and worst at the beginning, and change from prior headaches"- and if the patient doesn't have those complaints, then it makes it LESS likely they have a SAH.  The only way you can "rule out" a SAH is a neg CT and neg LP- you've done all the diagnostic studies necessary to actually say you "ruled out" a problem like that.  But recognize this is rare- you rarely "rule out" things in the ED definitively- your chart just reflects that those life-threatening diagnoses are less likely than more benign conditions.  THIS is what you're to be charting, and (hopefully) what your attending is hinting at.  

 

For instance, an 18-year-old with chest pain- the documentation in reference to PE might be something like "18 y/o with > 24 hrs chest pain, constant in nature, no exacerbating or relieving factors.  Pt is PERC neg and Wells score is low-risk. Pt is well-appearing, no accessory muscle use and is in no acute distress".  With this sentence, I have communicated that I believe PE is very unlikely in this patient.  

 

Your job in the ED is ruling out life-and limb-threatening diagnoses.  Your charting should reflect this.

[Derbingle]

Quick example; when you get to medical decision making, if you work some one up for a headache and list DDX is tension, migraine, deyhydration and meningitis or SAH, you have to be able to address them as they say above "not likely due to xyz". But you cant just "decide"there isnt any bleed without intervetion and not addresss it. I learned in PA school that r/o dx arent encouraged unless its an ongoing investigation o.w r/o dx is incomplete.

[NewtonsApple]

Thanks for the responses. The feedback is helping. Shot in the dark, but any resources that show pitfalls, pearls, billing issues, etc. of EM charting or charting in general. I found some info online dealing with liability which helped some, but something more detailed would be nice to review. 

[fireguy]

I always add "clinical picture does not suggest..."  and then list the pertinent "lethal" diagnosis from my differential