Patient charting. Am I charting too much?

[risktaker]

Hey all,

 

So I have noticed while working in urgent care that almost all providers have absolutely nothing in their MDM and most of them don't even have an MDM. We see pretty heavy volumes, between 40-60 in 12 hr period, but I am always astonished that providers including docs have next to nothing in their MDM aside from something to the likes of "if symptoms worsening, go to the ER".

 

My question is, will this kind of charting ever hold up in court if you get sued? By that I mean, if you document HPI, exam, and ROS well, but nothing in MDM aside from if symptoms worsen, go to ED.

 

Also, are urgent care providers supposed to call ER and give patient report everytime you send someone to the ER? I am asking this question from medical legal side. If I ever got sued, would not giving report to ED provider be held against me?

 

Thanks for all responses!

[ventana]

MDM is your best friend

 

Let's others see what you are thinking

 

40-60 patients - this is too much - an if you have time to do MDM charting, well then I still don't understand how you could see 40-60 patients in one 12 hour shift and be doing good medicine....

[DogLovingPA]

No you are not charting too much, your coworkers are not charting enough. I'm in a very similar environment - high volume urgent care and the charts of my coworkers drive me crazy. Most of the time I can barely understand them due to the nature of EMR. There are many good posts about charting on this forum and I've learned a lot and adjusted my charting for the better after reading them. I always try to include at least one sentence for even the simplest complaints in my a/p. Ie: well appearing healthy 10 yo with positive rapid strep test in office, treat with pen vk. Some patients I have a couple paragraphs so that if they come back, the next person seeing them knows what the heck happened with my visit.

 

As for calling the ER, I don't know the answer in terms of legal ramifications however I feel like it is general courtesy to give them a heads up that you are sending them a patient and why. Often I even send the patient with a piece of paper they can hand to the triage nurse that lists the basic s/s, any pertinent exam findings, results of any testing done and any specific concerns I have.

[DogLovingPA]

To add to my above post - the patient (and sometimes even EMS if you send them by bus) often will not accurately convey to the ER why they are there.  The patient does not want to be sick, they do not want to be in the ER and they are mad they came to urgent care and were sent to the ER.  

 

Example:  

 

Triage nurse to patient:  "What brings you in today?".   Patient:  I went to urgent care A and they told me my chest xray looks funny and sent me here.

 

Real reason:  Middle aged male with non specific off/on chest discomfort for a few days and CXR showing widened mediastinum that I can't tell whether is a tortuous aorta or an aortic dissection   (don't worry, this patient went via ambulance)

 

Call the ER.  

[beattie228]

I am pretty diligent about including as much of the pertinent information as possible. While it may be a bit verbose, I feel it helps to paint a clearer picture for not only the clinicians who treat the patient after me but also for any prying attorney's later down the road. It's my opinion that you can never be too articulate about your MDM and the questions you asked, even when working in a fast paced environment like UC. I find this to be especially so for the pertinent negatives. Additionally, if I'm ever deposed for a patient in question, the additional information will help to jog my own memory about what I did for them and why I chose a specific route.

[BruceBanner]

So I work in a huge corporate system, where everything is tracked and measured. There is a lot of risk management. What I do is list the Dx or likely Dx, and note that I considered or doubt more serious things in the differential and why. Just a sentence or two. Like "doubt sepsis, pt afebrile, non-toxic. Doubt PE given hx and low pre-test probability, etc".  Also highlight the pertinent exam findings.

 

When cases go to peer review they just want to see that you considered the alternatives and have appropriate reasoning.

[LKPAC]

I remember the old days of handwritten charts:

 

S: sick

O: looks sick

A: is sick

P: Amox

[Evolute]

Hey all,

 

So I have noticed while working in urgent care that almost all providers have absolutely nothing in their MDM and most of them don't even have an MDM. We see pretty heavy volumes, between 40-60 in 12 hr period, but I am always astonished that providers including docs have next to nothing in their MDM aside from something to the likes of "if symptoms worsening, go to the ER".

 

My question is, will this kind of charting ever hold up in court if you get sued? By that I mean, if you document HPI, exam, and ROS well, but nothing in MDM aside from if symptoms worsen, go to ED.

 

Also, are urgent care providers supposed to call ER and give patient report everytime you send someone to the ER? I am asking this question from medical legal side. If I ever got sued, would not giving report to ED provider be held against me?

 

Thanks for all responses!

 

Having been through (as a witness) one ~4 hour deposition as a paramedic, one trial, felony assault with a weapon (Solo ED coverage), and one murder trial (again, solo ED coverage). IMHO you can never chart to much. To answer your first question, no you are not charting to much. 

 

As for calling the ED, In Montana (I cannot speak for other states) there is no legal obligation to call the ED if you are sending a pt from a clinic (FM or specialty) or UC to call the ED. Having said that we encourage, and welcome a provider to provider report. Because most of the time the pt shows up with a cc of I went to the UC/clinic and they told me to go to the ER because they said I have "bad" (happened to me yesterday) labs. Having that provider to provider conversation is important (IMHO). Knowing the reason of why the pt was sent to the ED is important, abnormal labs, imaging? The transferring provider can give all that information and (sometimes) make our job easier.  Personally, I never even mention the call report from the UC/clinic provider in my chart. Example. pt presented to xxx UC/clinic with a xxxx day hx of dyspnea and cough labs and chest XR done at the UC/clinic showed consolidations consistent with pneumonia with an elevated wbc at xx. pt was subsequently referred to the ED for further workup and evaluation....

 

Honesty, if you send a pt from UC to the ED how could that report be used against you? You sent a pt to a higher level of care (in most cases).

[risktaker]

Thanks a lot everyone! Very helpful. Will continue to chart how I should be.

[jusgatr]

I remember the old days of handwritten charts:

 

S: sick

O: looks sick

A: is sick

P: Amox

 

I'll add...ortho spine

S: post-op #

O: looks fixed

A: will fix again at some point

P: narcs. Hopefully they don't come back (pun intended)

[DizzyJ]

I started a new job last week.  While waiting to be set up with EHR I spent a day seeing patients with my manager (an NP) and then she walked me through charting under her EHR.  I asked her if there was a specific field for MDM.  I saw the blank look on her face and she had no idea what MDM meant.  So, I just free typed out my paragraph of MDM and she said since I am charting under her name the chart needs to look like her charts.  She said MDM is a "PA thing" and she doesn't do that.  I then deleted my paragraph.  MDM is perhaps the most important part of your charting.  *sigh* I don't understand. 

[Reality Check 2]

I was taught lo so many years ago before the internet or EMR to paint a picture with my charting such that the next provider to read my chart would know what I was thinking. Thankfully, I have legible handwriting.

 

I never called it MDM - it was just a part of the thought process, the differential and explaining why I did what I did and why I didn't do other things.

 

It is truly a lost art that needs to be brought back. 

 

It is sad that it has to be thought of sometimes in the litigious fashion but it truly is a message to other providers about what was going through the mind while seeing the patient.

 

Notes need to say things such as - "chest wall tender and pain with deep inspiration more consistent with costochondritis although patient has risk factors for cardiac etiology."

 

Or - "strongly suspect DVT and provided patient with samples of Xarelto with instructions to start on after I speak with them by phone after STAT U/S. If not DVT then would consider muscle tear and re-evaluate in office and start Physical Therapy or imaging to demonstrate degree of tear and set up rehab timeline." 

 

It really is never ok to just put - calf pain and leave it at that. 

 

EMRs have not taught very good habits in my opinion - especially those that require copious clicks on drop downs instead of true descriptors and allowances for discussion.

 

Alas, I am old and verbose......................