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quoting "rules" in your note

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Many common ER scenarios have rules that have been tested to help with decision making. using these in your notes helps bolster your medical decision making and can protect you in the event of a later poor outcome. Ones I use frequently:

Nexxus and Canadian c-spine

Pecarn for peds head injuries

Perc for PE

Heart score for ACS

abcde2 for tia risk of progression

Port score for pneumonia

Chad score for anticoagulation of afib.

Ottawa ankle rules

Canadian head ct rules

those are the ones I use the most. there are others. most on mdcalc website

most of you seasoned ER folks probably already know this and many of you likely do it.

please feel free to add to my list.

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10 hours ago, radioman said:

Just out of curiosity how much weight do these actually carry in the event of a misdiagnosis and some bad outcome assuming you calculated it correctly?

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good question. couldn't hurt to have a well-respected diagnostic tool quoted appropriately in your note if the perc neg pt has a PE or the abcd2 pt has a cva the same day they are d/c after a TIA. I think it would be easy to find professional witnesses who would say they did the same thing, assuming no gross negligence.

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I have frequently listed documentation references to “patient doesn’t meet criteria for x based on y guidelines.”

Playing devils advocate, regardless of your resource, if the standard of care in your community is different then you could be on the hook. Ex.-MMG, PSA screening, failure to check one month CXR after pneumonia dx.

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  • 1 month later...

New one I heard about recently: Ottawa Subarachnoid Headache Rule to rule out testing for SAH in acute headache. Pretty helpful. https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation

Validation: https://www.ncbi.nlm.nih.gov/pubmed/29133539

Also, I don't use this one often because I find it redundant, but it's a good reminder for newbies who are still figuring out who needs to be admitted: San Francisco Syncope Rule https://www.mdcalc.com/san-francisco-syncope-rule

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I take a bit of a contrarian approach, as I tend not to use rules as they are protocol driven and unless something is absolutely straight-forward, I am a touch reserved such that my reliance on something like the PERC rule (which allows for about a 1.7% miss rate on PEs) will come back to bite me in the buttocks.  There are times I do use them of course, but patient presentation first and if anything is amiss (and I think about it from someone else looking at - it's too easy to fall into a cognitive bias of what we want to see vs. what is objective) I investigate and treat regardless of the rule. 

The only ones I use are:

PERC or Wells (or together)


PORT Score

Peds Appendicitis Score

FENa Scores

CENTOR Criteria (even though ABX now recommended for hold until positive culture - meh)

Working in ski country has taught me the Ottawa rules for orthopedic extremity trauma are pretty meaningless so I have stopped relying on them.  Worked great when I worked at an academic medical center.  Following them in ortho trauma heaven leads you to miss a lot.   

All else is look at the patient and treat them...


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  • 10 months later...

Most of the above are good. I also like to reference the San Francisco Syncope Rule. Also, keep in mind that the ABCD2 score hasn't been validated, particularly for ED use, so I wouldn't use this - just admit all TIAs for workup or discharge AMA if they refuse. Our EM group actually wants us to reference HEART scores for all chest pain patients.

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