The Documentation

You can do all of the right things and give excellent patient/family education, but if you don’t document it properly, it may as well never have happened. Let’s look at this case. First, document why a pelvic exam was not done (denial of sexual activity, age, no history of vaginal bleeding or discharge, unilateral pain, etc.), that the risk of misdiagnosis that could result from not doing a pelvic exam was explained to the patient, and that there will be close follow-up with an ob.gyn. Second, document anything from sign-out that is needed, such as confirmation of history, focused exam findings, and the like. Third, always document when you have reevaluated the patient, and give the time and a brief description. This may be just quickly popping your head in the room and observing that the patient is laughing and eating. Most important in abdominal pain, document the time and exam findings of serial evaluations, particularly just prior to discharge. Fourth, document the precautions given to the family and that the family understands, especially with regard to when they should return for further evaluation. Fifth, document the follow-up time and that the family understands why this is important. Finally, it is especially important to document any red flags (such as a small amount of free fluid in the pelvis) and demonstrate that you thought about it, explained it to the patient/family, and gave strict precautions relating to it. This may sound burdensome, but it can be done quickly and does not require a dissertation, particularly if you have a good system for discharge instructions.

The Ultimate Judgment

You are likely to be sued in your career—at least once. However, you have a lot of control over how that case goes. Often a physician is brought in on a lawsuit because he or she was one of many people to see the patient, not because that physician did anything wrong. Get into the habit of thoughtful evaluation, careful handoffs, excellent documentation, and a thorough explanation to the patient/family of risks and the importance of vigilance. You cannot eliminate risk for your patients, but you can certainly go a long way toward ensuring better outcomes for them and minimal litigation risk for yourself.

Dr. Stankus is a senior emergency medicine resident at the University of New Mexico, a veteran member of the ACEP Medical-Legal Committee, and a frequent contributor to ACEP News.