"ED Precautions Given"

[thegenius]

You guys ever read outpatient notes? You know when doing chart reviews for ER patients?
Why is there such emphasis in the majority of those notes that "ED Precautions Given"
Is this some sort of requirement by CMS? Of course it's CYA.

Sometimes "ED Precautions Given" is more prominent than the reason why they were in the clinic to begin with.

I was last in residency about 10 years ago...and I don't recall reading that phrase nearly as much.

What would happen if the notes never had that phrase? Would outpatient doctors and nurses get in trouble if there was a bad outcome and "ED Precautions given" or some similar phrase was never in the chart?

ED PRECAUTIONS GIVEN!!!!!

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[RustedFox]

Doesn't matter.
People can't read anyways.

 

[pkwraith]

ED precautions = "If your symptoms get worse or don't get better, go to the ED"

Five minutes later:
"My doctor told me to go to the ED"

 

[Groove]

You guys ever read outpatient notes? You know when doing chart reviews for ER patients?
Why is there such emphasis in the majority of those notes that "ED Precautions Given"
Is this some sort of requirement by CMS? Of course it's CYA.

Sometimes "ED Precautions Given" is more prominent than the reason why they were in the clinic to begin with.

I was last in residency about 10 years ago...and I don't recall reading that phrase nearly as much.

What would happen if the notes never had that phrase? Would outpatient doctors and nurses get in trouble if there was a bad outcome and "ED Precautions given" or some similar phrase was never in the chart?

ED PRECAUTIONS GIVEN!!!!!

I put "Return precautions discussed"

Kind of the same thing I guess. Just a short hand way of saying we discussed a paragraph worth of symptoms to look out for and they were instructed to return if any of them manifest.

 

[VA Hopeful Dr]

I put "Return precautions discussed"

Kind of the same thing I guess. Just a short hand way of saying we discussed a paragraph worth of symptoms to look out for and they were instructed to return if any of them manifest.

Pretty much this. If I put that in a note it means I said "if this gets worse go to the ER".

 

[BoardingDoc]

You guys ever read outpatient notes? You know when doing chart reviews for ER patients?
Why is there such emphasis in the majority of those notes that "ED Precautions Given"
Is this some sort of requirement by CMS? Of course it's CYA.

Sometimes "ED Precautions Given" is more prominent than the reason why they were in the clinic to begin with.

I was last in residency about 10 years ago...and I don't recall reading that phrase nearly as much.

What would happen if the notes never had that phrase? Would outpatient doctors and nurses get in trouble if there was a bad outcome and "ED Precautions given" or some similar phrase was never in the chart?

ED PRECAUTIONS GIVEN!!!!!

I'm not sure that this is any different than our charts. I end most of my charts with something like "return precautions discussed" or something similar. The only difference is instead of sending them to the ED, I'm telling them to come back.

 

[Birdstrike]

...
Why is there such emphasis in the majority of those notes that "ED Precautions Given"...

ED PRECAUTIONS GIVEN!!!!!

In world where your liability goes down 10% with every additional exclamation point, it makes perfect sense.

 

[southerndoc]

Documentation of "return precautions" and "ED precautions" don't do much in litigation. You have to document what specifically you advised them.

 

[BoardingDoc]

Documentation of "return precautions" and "ED precautions" don't do much in litigation. You have to document what specifically you advised them.

I don't usually write specifics in my chart, but I have various macros with specifics that I include in their DCs.

E.g. for neuro complaints:

Go to the nearest emergency department if you have any new or worsening symptoms, severe headache, vision changes, multiple episodes of vomiting, confusion, numbness or weakness in your arms or legs or for any other concerns.

I've got similar things for back pain, abd pain, chest pain, urinary sx etc etc etc... I'm assuming that since that's also a permanent part of their chart that I'll be fine, but if some of you more medicolegally savvy folks disagree I might need to start throwing this nonsense into my MDM as well.

 

[Tenk]

Btw, you should always write specific symptoms (in addition to “any new or worsening symptoms”) that might be relevant to bounce back or litigation. Ie: fractures think compartment syndrome or circulatory/nervous system compromise or DVT (pain, color change, swelling, numbness, weakness). This has been proven to reduce liability rather than vague blanket statements because prosecution will argue the patient didn’t know what symptoms to watch for.

 

[southerndoc]

I don't usually write specifics in my chart, but I have various macros with specifics that I include in their DCs.

E.g. for neuro complaints:

Go to the nearest emergency department if you have any new or worsening symptoms, severe headache, vision changes, multiple episodes of vomiting, confusion, numbness or weakness in your arms or legs or for any other concerns.

I've got similar things for back pain, abd pain, chest pain, urinary sx etc etc etc... I'm assuming that since that's also a permanent part of their chart that I'll be fine, but if some of you more medicolegally savvy folks disagree I might need to start throwing this nonsense into my MDM as well.

That's even better. You've written it into a document that the patient receives. So they can't say you didn't inform them.

 

[PianoMedic]

I don't usually write specifics in my chart, but I have various macros with specifics that I include in their DCs.

E.g. for neuro complaints:

Go to the nearest emergency department if you have any new or worsening symptoms, severe headache, vision changes, multiple episodes of vomiting, confusion, numbness or weakness in your arms or legs or for any other concerns.

I've got similar things for back pain, abd pain, chest pain, urinary sx etc etc etc... I'm assuming that since that's also a permanent part of their chart that I'll be fine, but if some of you more medicolegally savvy folks disagree I might need to start throwing this nonsense into my MDM as well.

This is also what I do. I have macros for certain major complaints. Cerner saves them as a separate document in the chart that I’ve signed so it’s part of the medical record, but in my note I just freetext in that we’ve had the discussion during which I usually cover those reasons to return (I probably miss a few but then it is also written down for them).

 

[Groove]

Documentation of "return precautions" and "ED precautions" don't do much in litigation. You have to document what specifically you advised them.

I hear this a lot but I've never seen or heard of a case where simplification of generalized precautions broke a defense. In fact, I asked my malpractice attorney that very question one time and he told me that it all really depended on the case in question and the cleverness of the defense attorney. I also found it interesting that he told me you don't necessarily have to mention everything in the physical exam. He told me about a client he defended one time (OMFS? Dentist?) where an oral abscess was missed and the pt ended up septic +/- endocarditis, etc.. and the examination during the office visit didn't mention the presence or absence of a dental abscess. The defense? If there had been an abscess...the doc would have mentioned it. The very fact that he didn't include description of an abscess essentially excluded the presence of an abscess. It sounded ridiculous but it was a successful defense in that case. It's kind of like surgeon's that say in their pre-op note...."pt educated on risks of surgery including but not limited to x,y,z" You can't be expected to document every single risk, warning symptom and/or return precaution. Nor do I think a jury would think you'd have to mention every little thing in your note, otherwise it would be 20 pages long. More than likely, you'd just have to make a strong defense that you made the effort to educate the patient on return precautions and that their symptom in question would have been included in your discussion.

If some of you guys that do case reviews and/or have more malpractice experience have seen a case that revolved around specification of return precautions, I'd love to hear about it. I'm genuinely curious.

 

[southerndoc]

I hear this a lot but I've never seen or heard of a case where simplification of generalized precautions broke a defense. In fact, I asked my malpractice attorney that very question one time and he told me that it all really depended on the case in question and the cleverness of the defense attorney. I also found it interesting that he told me you don't necessarily have to mention everything in the physical exam. He told me about a client he defended one time (OMFS? Dentist?) where an oral abscess was missed and the pt ended up septic +/- endocarditis, etc.. and the examination during the office visit didn't mention the presence or absence of a dental abscess. The defense? If there had been an abscess...the doc would have mentioned it. The very fact that he didn't include description of an abscess essentially excluded the presence of an abscess. It sounded ridiculous but it was a successful defense in that case. It's kind of like surgeon's that say in their pre-op note...."pt educated on risks of surgery including but not limited to x,y,z" You can't be expected to document every single risk, warning symptom and/or return precaution. Nor do I think a jury would think you'd have to mention every little thing in your note, otherwise it would be 20 pages long. More than likely, you'd just have to make a strong defense that you made the effort to educate the patient on return precautions and that their symptom in question would have been included in your discussion.

If some of you guys that do case reviews and/or have more malpractice experience have seen a case that revolved around specification of return precautions, I'd love to hear about it. I'm genuinely curious.

It all depends... You can claim that you have the same customary instructions you give to all your patients diagnosed with xyz, but some plaintiffs can make an issue with it. What @BoardingDoc mentioned is best... macros that go in the patient discharge instructions. That plus documentation in your note that you discussed return precautions with the patient is pretty much solid and incredibly defensible.

I'm aware of a case where an orthopedic surgeon claimed to have given instructions for when to return for possible compartment syndrome, but he only documented "precautions given for when to go to the ER." Case ended up settling. I also know of a case where the text messages from one surgeon to another was obtained and used against the defendant.

My case has been dropped, but I'm still not at liberty to discuss it. There is potential -- although unlikely -- that I may be named again when the plaintiff refiles against the non-settling party. One party settled, I was dropped, and another party is likely to be named again. I will await for final resolution before I post the details of my insanely absurd case for which I had absolutely zero culpability for and definitely will be an eye opening experience that will change the way you document things once you hear about the case.

 

[turkeyjerky]

My takeaway from my lawsuit (from a case I was involved in as a resident from which me and the attending were ultimately dropped after the hospital settled based on ****ty inpatient care) is that claiming something, ie discussing return precautions or a certain physical exam finding, is part of your 'usual and customary care' and thus was performed even if not documented is a legitimate argument to raise, but is less useful than actually having documented it.

 

[Groove]

It all depends... You can claim that you have the same customary instructions you give to all your patients diagnosed with xyz, but some plaintiffs can make an issue with it. What @BoardingDoc mentioned is best... macros that go in the patient discharge instructions. That plus documentation in your note that you discussed return precautions with the patient is pretty much solid and incredibly defensible.

I'm aware of a case where an orthopedic surgeon claimed to have given instructions for when to return for possible compartment syndrome, but he only documented "precautions given for when to go to the ER." Case ended up settling. I also know of a case where the text messages from one surgeon to another was obtained and used against the defendant.

My case has been dropped, but I'm still not at liberty to discuss it. There is potential -- although unlikely -- that I may be named again when the plaintiff refiles against the non-settling party. One party settled, I was dropped, and another party is likely to be named again. I will await for final resolution before I post the details of my insanely absurd case for which I had absolutely zero culpability for and definitely will be an eye opening experience that will change the way you document things once you hear about the case.

Def post about it when you can. I've got a similar case that was dropped that I'm itching to post about and although it's been over a year which was supposed to be the timeline of when they could re-sue...they haven't so I should be ok posting about it but I'm giving it a little bit more time. It was beyond absurd.

Now you've got me paranoid. Somebody should start a thread on nothing but smart phrases and macros. I bet it would get stickied if enough people contributed.

 

[RustedFox]

Def post about it when you can. I've got a similar case that was dropped that I'm itching to post about and although it's been over a year which was supposed to be the timeline of when they could re-sue...they haven't so I should be ok posting about it but I'm giving it a little bit more time. It was beyond absurd.

Now you've got me paranoid. Somebody should start a thread on nothing but smart phrases and macros. I bet it would get stickied if enough people contributed.

I'm all for this.

Here's my general approach:

"Return immediately for any new, recurring, prolonged/progressing, unfamiliar or concerning symptoms; or for any changes in your condition."

It's generalized, I know.

 

[Apollyon]

"Return to the ED if you have nausea and vomiting, if you are worse in ANY way, or you think you need to be seen again."

Defense Attorney: You were vomiting the prescribed medications. Why didn't you return?

Plaintiff: ??

DA: You stated that you felt worse. Why didn't you return?

P: ??

DA: You felt that you needed to be seen again. Why didn't you return?

P: ??

This is how it was explained to me by another doc many, many years ago. Very fortunately, this was only an academic exercise in my career.

 

[thegenius]

I'm not sure that this is any different than our charts. I end most of my charts with something like "return precautions discussed" or something similar. The only difference is instead of sending them to the ED, I'm telling them to come back.

I almost never tell patients to come back to the ER. Just about everything needs either outpatient follow-up or admission. There are of course some borderline cases where they don't need to be admitted but don't have follow-up at all, and they can be tough.

I tell patients to see their doctor in 'x' days, and 'x' is always >= 3. It's often in 1-2 weeks. Things like diverticulitis, pneumonia, cellulitis, syncope, low risk chest pain, pyelonephritis, new anemia, new diabetes, and the list goes on.

 

[Mbekweni]

Many an ER doctor I know has discharged a patient with a subjective fever or minor issue and instructions to “follow up with PMD in 1-3 days”. It runs all directions, trying to find some shred of additional legal protection.

 

[turkeyjerky]

Interesting. I always tell patients to followup within 1-2 days (well that's what it says in the followup section of the d/c paperwork...). Other than lacs, in which I put the timeline for suture removal and any reasons to f/u sooner or return to ER for.