moestown1016 Posted September 28, 2016 Share Posted September 28, 2016 Anyone feel like sharing some personal experience advice on the dos and dont's of charting techniques from a legal perspective? Maybe something someone has shared with you or something that's happened to you without going into great detail in case the case is still pending. For instance I was taught do not chart something you didn't actually do (seems like a no brainer). I was also told don't put cranial nerves II-VII intact because you really can't say that unless you did a superb neuro exam. I've been listening to some podcasts on different topics most lately low back pain disasters to try and improve my exam and documentation and keeping the big bad uglies in mind so I don't miss them. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 28, 2016 Share Posted September 28, 2016 Don't just notate positive subj./obj. findings but also note pertinent negatives. Your negatives helps tell a story of what you were thinking of in your differential. Link to comment Share on other sites More sharing options...
moestown1016 Posted September 28, 2016 Author Share Posted September 28, 2016 Don't just notate positive subj./obj. findings but also note pertinent negatives. Your negatives helps tell a story of what you were thinking of in your differential. Agree. Just wish there was a resource I could review cases and how the attorney breaks the chart down to every word. Friend said when he was questioned they even questioned "is this a normal blood pressure?" When it was a little high (like SBP 130) He replied it's "normal" in an ER when someone is sick or uncomfortable or have anxiety from being there blood pressures like that do not alarm us. Like come on. Nit pick. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
slolar Posted September 29, 2016 Share Posted September 29, 2016 BounceBacks by Michael Weinstock is a great book. It takes actual charts with bad outcomes (a bounceback). They discuss what's good or bad in the charting, the legal proceedings etc. Really a great book. CCME.org group has a good podcast called "Risk Management Monthly" that I subscribed to for a bit. Anything with Greg Henry is generally funny, enjoyable. He's a lawyer AND and ED physician. Sara Link to comment Share on other sites More sharing options...
moestown1016 Posted September 30, 2016 Author Share Posted September 30, 2016 BounceBacks by Michael Weinstock is a great book. It takes actual charts with bad outcomes (a bounceback). They discuss what's good or bad in the charting, the legal proceedings etc. Really a great book. CCME.org group has a good podcast called "Risk Management Monthly" that I subscribed to for a bit. Anything with Greg Henry is generally funny, enjoyable. He's a lawyer AND and ED physician. Sara Pretty sure he spoke at a conference I went to recently. Great info!!! Thanks! Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
SERENITY NOW Posted September 30, 2016 Share Posted September 30, 2016 I'll second Greg Henry. He is a legend in the realm of medico legal. More good book resources: Amal Mattu's "Avoiding common errors in the emergency department", and "Urgent care emergencies: avoiding the pitfalls" Bouncebacks: Medicolegal (another one along same lines of Bouncebacks:'ED returns') Podcast realm: Crico medical malpractice Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted September 30, 2016 Share Posted September 30, 2016 Charting consults: TImestamp: both when paged & when actually had the interaction Consultant's name, speciality, and why them: on-call for that specialty, patient preference or has hx with that person What data you provided the consultant: imaging, labs, HPI, physical exam, also if they went online to the EMR and checked anything themselves What their reco's were, esp if they want something done and the patient d/c'd. What their recommended follow-up for the patient if d/c'd. Also chart that you discussed the consultant's reco' with the patient and they verbalized understanding, especially on when to follow-up. This way if there's a bad outcome, there's accurate info on what you were told and what the patient was told. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted September 30, 2016 Share Posted September 30, 2016 I was also told don't put cranial nerves II-VII intact because you really can't say that unless you did a superb neuro exam. I think that's ridiculous. You can do a gross test of II-XII and cerebellar in about 30 seconds. That's good enough for me to chart "II-XIII grossly intact". When I chart ROM on a joint I don't get out the compass to measure the angle of the ROM...I just chart "normal ROM" or "Good ROM". That just means I didn't find a problem. Another hint: I try to write that I "doubt" the worst case diagnosis for the presentation ("Doubt septic hip) just so I can prove that I did consider the diagnosis. Link to comment Share on other sites More sharing options...
GreatChecko Posted September 30, 2016 Share Posted September 30, 2016 I think that's ridiculous. You can do a gross test of II-XII and cerebellar in about 30 seconds. That's good enough for me to chart "II-XIII grossly intact". I think the key word is "grossly." Greg Henry (see above) recommends always writing that the CN were "grossly intact" unless you want some very difficult questions from a lawyer that just wants to make you look bad in deposition or in front of a jury. Link to comment Share on other sites More sharing options...
newton9686 Posted October 15, 2016 Share Posted October 15, 2016 Yeah I've been taught if you see them walk, talk, eat, do a couple quick tests to fill in the gaps, thats good enough to put CN 2-12 grossly intact. I wouldn't write without deficit or anything like that. Again, its all in the wording. Link to comment Share on other sites More sharing options...
marktheshark89 Posted October 15, 2016 Share Posted October 15, 2016 I was always taught to just describe what you did for the neuro exam rather than say CN II-XII intact...ex: eye brow raise symmetric, smile and frown symmetric, repeats whispered word in each ear, shrugs shoulders against resistance, etc Link to comment Share on other sites More sharing options...
Guest ERCat Posted October 15, 2016 Share Posted October 15, 2016 Mark the shark - that's exactly what i do. I have a whole template "squeeze eyes shut, puff cheeks, smile, frown, stick out tongue..." Etc and I just delete what I didn't do. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 15, 2016 Share Posted October 15, 2016 Mark the shark - that's exactly what i do. I have a whole template "squeeze eyes shut, puff cheeks, smile, frown, stick out tongue..." Etc and I just delete what I didn't do. This is about the only functional way to do so (using template). If not, you'd be seeing 1-2 patients per hour if that from all the specific notating. There is nothing wrong with the brief CN notation IF you actually check them correctly. I bet most folks who have been out a while can't even remember which motor and/or sensory test checks which CN, we only remember the processes with which to check. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 15, 2016 Share Posted October 15, 2016 I think that's ridiculous. You can do a gross test of II-XII and cerebellar in about 30 seconds. That's good enough for me to chart "II-XIII grossly intact". When I chart ROM on a joint I don't get out the compass to measure the angle of the ROM...I just chart "normal ROM" or "Good ROM". That just means I didn't find a problem. Another hint: I try to write that I "doubt" the worst case diagnosis for the presentation ("Doubt septic hip) just so I can prove that I did consider the diagnosis. Darn, I can't find that silly CN "XIII" anywhere. The things that I forget with aging. :-) Link to comment Share on other sites More sharing options...
jwells78 Posted October 16, 2016 Share Posted October 16, 2016 One thing I make sure to do is to justify my dx/tx in the medical decision making section: "Pt came in with (complaint) and had (workup). I have a low suspicion for (differentials) because of (pertinent negs); the clinical picture better supports (diagnosis) and will be treated with (treatment plan)." Paper charting makes it more time consuming to do this, so I used to dictate a quick med decision making on my sicker fast track patients, and ALWAYS a thorough one on mainside patients. It always surprises me when I read charts by my colleagues who dont do this, its such an simple thing to do and it has the added benefit of clarifying your workup and direction of care should the pt return to the ED. Oh, and YES YOU CAN CHECK CRANIAL NERVES 2-12 IN 30 sec. ???? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 16, 2016 Share Posted October 16, 2016 No Dx made that can't be explained by Hx/PE. Tx plan appropriate for Dx.. Sounds so easy but not so rarely do I find pertinent Hx/PE findings not addressed in Dx or Plan. Folks, it's really simple. Play "connect the dots" if for no other reason than covering your backside. Ex.-How do you justify discharging a tachycardic pt. w/o explanation or by documenting a normal rate in f/u vitals? [emoji869][emoji869] Link to comment Share on other sites More sharing options...
8404PA Posted October 16, 2016 Share Posted October 16, 2016 Paper charting makes it more time consuming to do this, so I used to dictate a quick med decision making on my sicker fast track patients, and ALWAYS a thorough one on mainside patients.What?? Current student always looking to streamline my notes or tips for the near future. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
jwells78 Posted October 16, 2016 Share Posted October 16, 2016 Our facility (up until a couple months ago) was still using template charting in the ED, which was a two-sided paper chart (now Cerner EMR ????) -Great for simple FT pts -tough to cram a good H/P and Med Decision making on more complex patients So instead of cramming a Med Dec Making, I would dictate a quick, concise paragraph and just throw the dictation number on the paper chart. -paper chart gets scanned into the system, dictation marries up with it Is that what you were asking? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 16, 2016 Share Posted October 16, 2016 With Cerner EMR, "!***" is your charting friend. I overload each Plan with preconfigured disclaimers. Same with default PEs for snot, conjunctivitis, UTIs, etc.. Now, if I could only preconfigure default prescription packages per Dx. instead of having to select each med individually. Link to comment Share on other sites More sharing options...
gbrothers98 Posted October 31, 2016 Share Posted October 31, 2016 With Cerner EMR, "!***" is your charting friend. I overload each Plan with preconfigured disclaimers. Same with default PEs for snot, conjunctivitis, UTIs, etc.. Now, if I could only preconfigure default prescription packages per Dx. instead of having to select each med individually. Thats easy. In Discharge Meds, set up folders in your favorites by diagnosis. For example, Asthma exacerbation gets prednisone or decadron and albuterol or Gout gets indomethacin. George Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
gbrothers98 Posted October 31, 2016 Share Posted October 31, 2016 1. Everyone gets time and action specific discharge instructions. 2. Make follow up appointments for patients. They leave with a documented time and date in hand. 3. You should document you discussed PE and diagnostic findings with patient, their families. Outlined treatment and answered questions and concerns. 4. Invite patients to call with questions or concerns and have a system set up to provide all pts with a followup call. 5. Dont order anything on your pt that you will not see results of prior to shift end unless you will follow or there is a system in place to provide follow up. Good luck George Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
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