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I'm a new grad working in EM and something they didn't spend much time on in school was charting/creating MDM's. What are some things you make sure to document to protect yourself against future litigation? I.e. documenting no s/sx of cauda equina in acute back pain, TIMI/HEART score to support your decision to discharge a patient to home, etc. 

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good question. I usually summarize the case in my mdm:

typically sedentary 55 yr old male with 24 hrs of nonradiating , sharp R sided chest pain at rest. given asa on arrival. cxr and ekg neg. d-dimer and enzymes x 2 sets neg. no response to ntg. VS stable and afebrile. pain reproducible with movement of R arm. Pt did spend 3 hrs gardening yesterday (which is more exercise than he typically does) and is r handed. nothing to suggest shingles or pathologic fracture. pain resolved with single tablets of tylenol with codeine and ibuprofen 600 mg. hx, exam, workup c/w musculoskeletal pain. doubt ACS/PE or other worrisome etiology. discharged to close pcp f/u with instructions to return at once to ED or call 911 if worse in any way.

basically what was your thought process and major workup positives and negatives that led to your conclusion and final dx. If you did a consult what was their recommendation, etc

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6 minutes ago, SHU-CH said:

Good advice above.

I also was always in the habit of tacking on a line at the end of the chart to the effect that the plans had been discussed with the patient and that the patient understood and agreed with the plan.

that is a checkbox in our emr(cerner) that I always check in the impression and plan section.

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Such an important part of the chart.  I have found that mostly ER skilled providers are the only ones that actually use an MDM section.  Everyone should though.  I was shocked when I started a new urgent care position and rarely does a provider discuss any MDM.  It is where you tell the story of why it is what it is and why it isn't what it isn't.  You are documenting that you thought of severe/life threatening differentials, other pertinent differentials, and how you excluded them. 

Working in urgent care my MDM is basically on repeat explaining why the signs and symptoms are consistent with a viral etiology and that there is no signs of a bacterial process....blah blah blah...antibiotics are not needed at this time. 

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Biggest areas of litigation in EM are:

1. Missed MI

2. Missed fracture

3. Missed foreign body

So consider and rule out or provide pt education that this may still be a concern.

Other concerns are the usual, is this pt pregnant? does this pt have a surgical adbomen? is this headache a SAH?

Start thinking that way and you will be drinking the EM koolaid to keep yourself out of trouble.

Good luck.

George

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yes, as George said above use the ROWS concept: Rule Out Worst-case Scenario:

dental pain? ludwigs

rash? infectious etiology

back pain? epidural abscess or AAA dissection, etc

that doesn't mean every back pain needs a ct or MRI, it means you need to think about the bad dx and state in your mdm: no fever, no ivdu, no worrisome comorbidities, pain c/w musculoskeletal etiology, etc etc

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I have a dot phrase I use for all of my discharges after I document my MDM just as EMEDPA said. It's about showing that you considered the life-threatening, worst case scenarios and why you don't think it's that. But then below that I use this phrase and I make sure all of the components actually took place:

"The patient was seen, examined, and the chart/vital signs were reviewed in the ER. Appropriate laboratory and imaging studies were obtained based on the patient's risk factors, history, and physical exam findings. The results were personally reviewed and interpreted and then reviewed with the patient/caregiver. The patient appears safe for discharge. Diagnosis and treatment plan explained in layman's terms. Counseled need for close follow-up with PCP or specialist as appropriate. Strict return precautions given. Patient/caregiver verbalized understanding and agreement. All questions were answered."

This has NOT been reviewed by an attorney and is something I put together after seeing how some of my docs did their charts. I have no idea if it's actually a defensible piece of writing, but I feel better documenting it. I say this so no one uses this and then blames me if they get sued and it's worthless. I am NOT an attorney.

Also, if I reviewed the case with the physician or if the physician actually saw the patient, I document that as well.

Welcome to defensive medicine. Always do the right thing and your documentation will reflect that.

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agree with above. also, if you offer someone something and they refuse, document it. if you feel strongly about it, have them sign an ama form. " Pt refused cardiac angiogram and possible stenting after discussion with cardiology given ekg changes and positive cardiac enzymes. wants to go home. advised of possible death or permanent disability. ama signed in presence of nurse ratchet. " 

This saved one of my colleagues butts. pt with obvious stemi refused cath lab and wanted to go to another hospital where his regular Dr worked. ama form said "if you leave now you will be dead within the hour". 7 witnesses. he was.

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Along those same lines, if you considered a test or therapy but decided not to pursue it after discussion with the patient, I like to document that by using the new hip term "shared decision making". This is especially valuable in children when we want to avoid ionizing radiation but getting the study is the only way to rule out actual badness.

For example, "7 yof pw generalized abdominal pain, nb/nb emesis x 3 over past several hours. afebrile, no leukocytosis, urine bland. radiology unable to visualize appendix on ultrasound. discussed risk/benefit of CT with mom and utilizing shared decision making, will defer study for now as child is feeling better and tolerating PO after treatment here. I do not suspect appendicitis but counseled mom that as we cannot rule it out, the patient needs close obs at home and should return immediately or go to nearest ED for worsening pain, fever or vomiting. otherwise to f/u with PCP tomorrow."

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