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Visit 1: A 50 y/o obese female presented to the ED for H/A, N/V x 2 days. No head injury and no other associated sxs. The physician documented her PMH and PSH were negative. Aside from a HR of 105, the documented exam was unremarkable (but limited). She continued to have H/A after IV fluids and Phenergan, so Dilaudid was ordered and the H/A improved. On dc, she felt well and was able to tolerate a PO challenge. The provider’s documentation had an inaccurate PMH and PSH, a fully templated exam except for tachycardia, a limited neuro exam of nothing more than alert and oriented, no mention of an abnormal WBC of 16, and no MDM. Dx: Headache. Rx for Norco and directed to f/u with her PCP.
Visit 2 (the next day): The patient returned and was seen by a different physician. She complained of H/A for 3 days, 8/10, constant, and progressively worse. The N/V reported yesterday resolved but noted a new onset of a pruritic rash only on her abdomen after taking the Norco. HPI was thorough. She reported a hx of migraines, HTN, and breast CA (remission). The ROS was a template and conflicted the HPI. “No rash”. Exam: 99.4, P 66, R 16, BP 118/75, Pulse ox is 93% but was interpreted as normal, 136 kg. A thorough neuro exam was documented. Her exam was otherwise unremarkable except skin which was (unedited) “warm, dry, no rash. Pruritic, red rash on abdomen after taking Vicodin.” The workup included a CT head which was negative. Repeat labs showed a WBC of 14.5 and Sodium of 129. The MDM possibly had a good thought process, but dictation typos made it difficult to understand. It was clear the physician was reassured by the slightly lower WBC and had no concern for meningitis. She was instructed to f/u with her PCP in 2 days, return if worse. Dx: Migraine. Rx for Compazine and Percocet.
Visit 3 (the next day): On this visit, the patient reported a new concern to yet another physician. The physician documented the patient developed
left arm pain from her axilla to her wrist when lowering herself down on her bed 8 hrs ago and pain is worse with movement.
She denied other symptoms. ROS was template except for reporting a headache and right forearm and upper arm pain.
The rest of the template reported all systems to be negative including no rash. Exam: Afebrile, P is 82, BP 90/53, O2 sat 100% on RA, 136 kg.
Painful ROM of right arm, no bony tenderness. There was tenderness over left biceps, 3/5 strength with flexion, 5/5 strength with extension.
Skin warm and dry. There is no mention in the documentation of looking at the abdomen for the rash from the prior day. An EKG and humerus X-rays were performed.
The physician's MDM says "this is an obese female with right arm pain that began while lowering herself down. Initial v/s revealed hypotension,
but repeat BP was unremarkable and she denies lightheadedness, chest pain, SOB. She has biceps tenderness without ecchymosis or hematoma.
She has limited strength secondary to pain, but full ROM. Pain improved with analgesia. Given the pain started abruptly upon lowering herself and X-rays were normal,
I feel this is likely a muscle strain. Consider out-pt MRI with PCP. Return precautions were given." Dx: Left arm pain. Suspected biceps strain.
O2 sat at dc is 93% on RA.
The same day she went to see her PCP and they were unable to obtain a BP.
Visit 4 (same day): She returned to the ED with bilateral arm pain. She was diaphoretic and ill appearing. Her labs showed multisystem organ failure. She was promptly evaluated, appropriately treated, admitted to ICU but expired the next day from overwhelming septicemia.
1. The fundamental purpose of documentation is first to aid continuity of care and enhance patient safety. Billing/reimbursement is another aspect, as well as defense if your care is called into question. Why were experts critical of the documentation on each of the first three visits?
2. The essence of the plaintiff’s claim was the lab results and v/s obtained in the ED were underappreciated as indicating an ongoing infectious process. Infection should have been on the differential for all visits, and some experts felt care was substandard because the providers failed to act on the lab results and abnormal v/s. Other experts were more supportive as there were no definite clues to an infectious process on the visits. Which physician did all experts feel had the most exposure in terms of liability?
3. When a patient has recurrent visits, what is best practice?
4. Biases affect our understanding, actions, and decisions around patient care and diagnostic errors are often the result of multiple interconnected biases. What types of potential biases could have been unconsciously present in this case?
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