Author: Veronica Theresa Tucci MD/JD (EM Asst Professor / Asst Residency Director, Baylor College of Medicine) // Edited by Alex Koyfman MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK) and Stephen Alerhand MD (@SAlerhand)

Many would argue that if you didn’t write it down, then it never happened.

This mantra speaks to the very heart of the legal profession. As Emergency Physicians, we are doers and know with absolute certainty that our efforts are never adequately captured by the written word. Can the written word really show how you brought a patient back to life? So it is understandable why I hear from my residents and frustrated colleagues that “I did not go into medicine to sit at a computer all day or spend hours after my shift filling out charts. I went into medicine to help people.”

As medical students and residents, we spend countless hours learning to perfect our history taking, physical exam skills, and procedural abilities. Yet in most training programs, little time or attention is spent on learning how to properly document the fruits of our labor, and as a result, the medical record often looks like a jumbled mess.

This mess has become the primary means of communicating with our colleagues and consultants. The medical record is also the basis for billing and payment of our services. Unfortunately, it also serves to insulate or expose us to liability. Medical malpractice attorneys can spend countless hours dissecting a chart that we wrote in only 15 minutes. They will scan line by line for inconsistencies, and any that they find will be blown up on large white boards for the jury to see. It is, therefore, essential that we learn how to master the art of medical documentation.

Please allow me to state upfront—I am far from perfect in my own documentation and learn lessons daily. I absolutely understand how documentation can slide during a busy overnight shift. I invite you all on a journey to improve our specialty’s documentation practices and embrace this as a lifelong learning process.

In anticipation of setting up my own blog on Emergency Medicine documentation pearls and pitfalls, I have been soliciting examples of good, bad, and ugly documentation from our colleagues around the country. The following case was submitted to me for review prior to a morbidity and mortality conference, and I was asked to provide recommendations for improving documentation. The patient in this case was brought in during a busy overnight shift for altered mental status and presumed intoxication. By morning, he was found to be paralyzed. All patient and provider identifiers have been removed, and this case is being submitted for educational purposes. My comments are embedded in ALL CAPS in the text of the actual chart, and then summary recommendations and pearls/pitfalls are noted below.

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History

Chief Complaint

Patient presents with: Altered Mental Status

HPI Comments: Patient brought in as a medical shock for hypotension (systolic 60s in field). Per EMS was found down after drinking with friends. Unknown of other ingestants, but family says he has a history of PCP use. Got narcan en route and was observed to respond. Presented severely altered, oriented to person only, and sluggish to respond. Does state “I took a lot of morphine pills.” When asked why says “I was in a fight and had pain”. Found to be hypothermic to 93.7 on initial vitals.

ANY PAIN COMPLAINT OR COMMENT SHOULD HAVE THE FULL PQRST (provoking/palliative, quality, radiation, severity and timing/duration) TO ELICIT FURTHER DETAILS OR STATEMENT THAT PATIENT UNABLE OR UNWILLING TO PROVIDE DETAILS.

The history is provided by the patient.

No past medical history on file.

No family history on file.

Review of Systems

Unable to perform ROS: Mental status change

There were no vitals taken for this visit.

MAKE SURE YOU GET A FULL SET OF VITALS DOCUMENTED. THE HPI NOTES AN INITIAL TEMPERATURE OF 93.7F BUT NO OTHER VITAL SIGNS ARE DISCUSSED

Physical Exam

Constitutional: He appears well-developed and well-nourished. No distress.

HENT:

Head: Normocephalic.

Nose: Nose lacerations (small 0.5cm superficial laceration on bridge of nose, too small to repair. ) present.

Mouth/Throat: Oropharynx is clear and moist.

Eyes: No scleral icterus. Right pupil is not reactive (sluggish). Left pupil is not reactive (sluggish).

TAKE CARE WHEN DOCUMENTING THAT PUPILS ARE NOT REACTIVE PARTICULARLY WHEN THERE IS A POSSIBILITY OF HEAD TRAUMA AND PATIENT FOUND DOWN. A MORE ACCURATE DESCRIPTION WOULD BE TO STATE MINIMALLY REACTIVE.

Pinpoint pupils bilaterally

Neck: Normal range of motion. No JVD present. No tracheal deviation present. No thyromegaly present.

NECK EXAM NOTES FULL RANGE OF MOTION. WAS THIS TRULY TESTED? IF SO, SHOULD IT HAVE BEEN IN VIEW OF NEXUS?

Cardiovascular: Regular rhythm and normal heart sounds. Bradycardia present. No murmur heard. HR in mid 60s.

IF HR IS IN THE 60s, IS THIS BRADYCARDIA AS WE KNOW IT?

Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.

Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness.

Musculoskeletal: He exhibits no edema.

WAS HE MOVING ALL EXTREMITIES? ANY GROSS DEFORMITIES?

Lymphadenopathy: He has no cervical adenopathy.

Neurological: He is alert. He is disoriented. No cranial nerve deficit. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 5.

OK SO THERE IS NO CRANIAL NERVE DEFICIT DESPITE THE FACT THAT THE PATIENT IS ORIENTED ONLY TO SELF PER THE HPI.

DOES ANYONE BELIEVE THAT A FULL CRANIAL NERVE EXAM WAS ACTUALLY CONDUCTED? IE, THE PATIENT REALLY SHRUGGED HIS SHOULDERS (ALSO SEE RN NOTE ON THIS LATER), RESPONDED TO SENSATION on V1-V3, STUCK OUT HIS TONGUE ETC.

ALSO HIS GCS WAS REALLY 14? HOW WAS HE LOCALIZING TO PAIN? STERNAL RUB?

THERE IS NO NOTATION OF PATIENT MOVING EXTREMITIES OR EXTREMITY STRENGTH OR SENSATION. THIS IS FAR EASIER TO ASSESS THAN A REAL CN EXAM ON AN INTOXICATED OR ALTERED PATIENT.

Skin: Skin is warm and dry. He is not diaphoretic.

HIS SKIN WAS WARM WITH A TEMPERATURE OF 93.7F?

Psychiatric: His speech is slurred. He is slowed and withdrawn.

Procedures

ED Course

A/P: 44 y/o M with unknown PMH presents with altered mental status and hypotension. +Hypothermia +Pinpoint pupils, +Slurred, sluggish behavior. Questionable opioid ingestion and Known EtOH use. Airway maintained, fluid responsive. DDX also includes intracranial bleed, intracranial contusion/concussion, sepsis, hypothyroidism, hypothermia.

POLYSUBSTANCE ABUSE/INTOXICATION SHOULD BE ON DDX EXPLICITLY.

THE FACT THAT THERE IS MENTION OF ICH ON THE DDX WARRANTS A FULL NEURO EXAM OR DISCUSSION OF WHY IT IS NOT POSSIBLE TO OBTAIN ONE.

ALSO IF ICH OR HEAD TRAUMA IS ON YOUR DDX, CAN YOU RULE OUT NECK TRAUMA UNDER NEXUS IN THIS PATIENT? HINT: NO DUE TO ACUTE INTOXICATION. THIS PATIENT WAS FOUND DOWN AND HAD AN ABRASION ON HIS NOSE THAT AT LEAST SUGGESTED POSSIBILITY OF FALL AND CERVICAL TRAUMA. HE SHOULD HAVE BEEN PLACED IN A COLLAR AND EITHER HAD IMMEDIATE IMAGING (CT HEAD AND CSPINE OR CT HEAD WITH SERIAL EXAMS) UNTIL SOBER AND SPINE COULD BE CLEARED CLINICALLY.

Labs: BMP, VBG, CBC/diff, UA, UDS, EtOH level, ASA, Salicylate,

Meds: 2L warmed fluid bolus

Imaging: CT head w/o contrast.

Will reassess after labs and imaging

YOUR PLAN SHOULD INCLUDE WHY YOU ARE ORDERING THE TESTS NOT THE MERE FACT THAT YOU DID. FOR EXAMPLE, WILL CHECK VBG AND LACTATE, UA TO R/O OR EVAL FOR SEPSIS. UDS AND ETOH FOR CONCERN OF POLYSUBSTANCE ABUSE/INTOXICATION.

ALSO IF HYPOTHYROIDISM IS REALLY ON YOUR DDX- WHY NOT CHECK A TSH?

WHAT IS THE PLAN TO ADDRESS THE HYPOTHERMIA? 2L WARMED SALINE. ANYTHING ELSE?

REMEMBER TO ORDER YOUR PROBLEM LIST AND THIS WILL HELP WITH PLANNED INTERVENTIONS.

PROVIDER REASSESSMENT NOTE

I reexamined the patient

Latest vital signs are:

Filed Vitals: BP: 88/53, Pulse: 66, Temp: 92.3 °F (33.5 °C), Resp: 16, SpO2: 95%

Interval Progress: Patient is sleeping, but easily arousable. Is more responsive an able to answer questions, though still a bit sluggish. Complains of right shoulder pain and refuses to move it, so will get X-rays. Repeat temp was 97.1 (oral). Still awaiting urine studies.

The patient’s condition is guarded.

Current clinical impressions include:

ALTERED MENTAL STATE Hypothermia Intoxication Abrasion of nose Drug ingestion Hypokalemia Hypotension Thrombocytopenia

Plan: Continue to monitor in the emergency department

LABS? CT FINDINGS?

YOUR DDX SHOULD GET REFINED AS YOU GO ON IN REASSESS NOTES. FOR EXAMPLE, CXR and UA clear NO EVIDENCE OF SEPSIS. ETC. TSH WNL. NO CONCERN FOR HYPOTHYROIDISM. ULTIMATELY, THIS PROCESS IN COMBINATION WITH REASSESSMENTS SHOULD ENABLE YOU TO FOCUS ON THE MOST LIKELY SUSPECT FOR THE PATIENT SYMPTOMS AND MAKE YOU ADDRESS THEM APPROPRIATELY.

TEACHING PHYSICIAN CRITICAL CARE NOTE

I examined the patient Mr. X, who at that time was critically ill and had a high probability of sudden significant deterioration in his condition as evident by altered mental status and hemodynamic instability and required my constant medical attention and the highest level of preparedness to intervene urgently.

44yM who was sitting with friends outside at a gas station and drinking alcohol until he slumped over. Found down by the paramedics and was hypotensive in the field with pinpoint pupils. 2L NS and 2mg narcan given.

Exam:

wnwd male

Hypothermic and hypotensive

Somnolent but responsive

Small abrasion to nose but no other e/o head trauma

JVD

abd soft nt nd

No extremity deformity

Alert to: Texas, self, President Obama

I reviewed the resident’s note and agree with the findings as documented in the resident’s note. Please refer to the medical record for detailed documentation of specific patient history, physical findings and medical assessment.

I provided 31 minutes of aggregated critical care services to this patient while he was in critical condition including: direct patient care, documentation time, obtaining additional history from EMS and ordering of diagnostic studies. The reported time excludes time spent on separately reportable procedures or services or time spent on resident(s) teaching.

I discussed the case with the resident and agree with the diagnosis of:

ALTERED MENTAL STATE Hypothermia Intoxication Abrasion of nose

and plan:

AMS: ddx: drug intoxication, ETOH intoxication, hypothermia, intracranial injury

-check UDS, ETOH, salicylate, apap levels

-EKG

-per history, no trauma however minimal 1-2mm abrasion to the nose, will consider CT head if no significant improvement after obs

NO HISTORY OF TRAUMA? PATIENT STATES HE WAS IN A FIGHT AND HAS ABRASION TO THE NOSE.

Hypothermia: 92.4F

-bair-hugger

-warmed fluids

-check EKG

-telemetry

Intoxication: presumed

-as above

Abrasion:

-could be e/o head injury although at present I doubt this, re-assess, and if no improvement will order head CT

-update Td

RN NOTES

First contact with pt in Room 3. Pt brought in by EMS, pt was found slumped over on a curb with a bottle of alcohol laying next to him. Pt was supposed to turn himself into the police today and started drinking before. Pt was altered and hypotensive at the time. EMS gave 2 liters of NS and started bilateral AC IV’S, and gave 0.2 of narcan with minimal response from patient. Pt presents AAOX2, pt aware of city and name, pt unaware of situation and time. Pt has heavy ETOH smell on breath. Pt states that he also took a lot of morphine pills tonight. Pt continually repeats himself stating “my shoulder hurts.” Pt refuses to move L shoulder, pt denies any other pain. Denies SOB, CP, Palpitations, N/V/D. Respirations even and unlabored, O2 sats at 96% on RA. Waveform capnography placed. NSR on monitor at 86. ABD soft and nontender. MAE, pulses palpable and cap refill < 3 seconds X 4 ext. Rectal temperature taken and pt was hypothermic, bair hugger placed. 2L warm IVF started. Labs drawn and sent as per order. MD team at bedside for eval

THE FIRST RN NOTE STATES THAT PATIENT WAS MOVING ALL EXTREMITIES (MAE). BOILERPLATE? OR REAL IN VIEW OF FACT EARLIER STATEMENT IN SAME NOTE THAT PATIENT REFUSED TO MOVE LEFT SHOULDER. ALSO MD REASSESSMENT NOTE HAS THE PATIENT COMPLAINING OF RIGHT SHOULDER PAIN. WAS IT LEFT, RIGHT OR BOTH?

IT IS ESSENTIAL TO REVIEW NURSING NOTES FOR BOTH HISTORY AND EXAM. SUCH DIFFERENCES IN THE MEDICAL RECORDS SHOULD BE DISCUSSED WITH RN AND DOCUMENTED IN YOUR NOTE.

IF PATIENT WAS ABLE TO MOVE ALL EXTREMITIES AS STATED IN THIS FIRST NURSING NOTE, FAILURE TO PROTECT C SPINE MAY HAVE RESULTED IN CRITICAL INJURY OCCURRING IN ED WHEN PATIENT WAS TRANSFERRED TO THE CT SCANNER. IF HE WAS NOT MOVING ALL EXTREMITIES, PT MAY HAVE DAMAGED CSPINE WITH PARALYSIS PRIOR TO ARRIVAL. THIS IS WHY IT MATTERS TO REVIEW RN NOTES. DID MOVING HIM TO CT SCANNER CAUSE THE FINAL DISRUPTION LEADING TO PARALYSIS IF HE WAS TRULY ABLE TO MOVE ALL HIS EXTREMITIES ON ARRIVAL.

Second RN note:

First contact with 44yo male who presented to the EC with hypothermia. Patient reported ingesting morphine and alcohol .Patient is AOX4 . Patient unable to move all extremities. Skin is intact and consistent with ethnicity. Cap refill < 3 seconds. Respirations even and unlabored with symmetrical chest expansion. Bilateral lung sounds CTA. S1, S2 audible with RRR. Bowel sounds normoactive all quadrants. Denies nausea, fever and vomiting.

RN NOW NOTE UNABLE TO MOVE ALL EXTREMITIES. ALTHOUGH THE RN STAFF SHOULD COMMUNICATE SUCH FINDINGS TO THE MD IN CHARGE OF THE PATIENT’S CARE, YOU ARE STILL RESPONSIBLE FOR ROUTINELY REVIEWING RN NOTES ON YOUR PATIENTS AND REASSESSING WHEN APPROPRIATE.

IN THIS CASE, THE SECOND RN HAD COMMUNICATED TO THE ED ATTENDING WHO TOOK SIGN OUT FROM HIS COLLEAGUE ON THIS PATIENT IN THE INTERIM. THE NEW ED ATTENDING (ATTENDING #2) ORDERED A CT OF THE CERVICAL SPINE BUT DID NOT DOCUMENT A REASSESS NOTE. MOREOVER, ATTENDING #2 ORDERED A CT OF THE CERVICAL SPINE AND DID NOT PLACE PATIENT IN C COLLAR PRIOR TO THE SCAN AT LEAST ACCORDING TO RN NOTE #3 (BELOW).

PRIOR TO THE MORBIDITY AND MORTALITY CONFERENCE, ATTENDING #2 STATED HE WAS INFORMED BY ATTENDING #1 THAT PATIENT WAS MERELY AWAITING CLINICAL SOBRIETY AND REASSESSMENT WITH ANTICIPATED DISCHARGE HOME. HOWEVER, THERE ARE NO TRANSFER OF CARE OR ACCEPTANCE OF CARE NOTES FROM ATTENDING #1 or ATTENDING #2, REVIEWING H&P, STUDIES ORDERED AND RESULTED.

Third RN note:

Patient received from night shift RN. Informed by MD that patient has C3 spinal fracture with swelling. Patient lying in bed with complaint of not feeling arms and legs and the inability to move them, respirations even and unlabored. Placed c-collar on patient at this time and HOB flat for full spinal precautions, Patient stating that he got in a fight on Thursday and has had neck pain since the occurrence, patient states that he took his wife’s morphine for the pain and doesn’t recall what happen but thinks that he was found in a friend’s car and doesn’t recall a fall prior to being picked up by EMS. Patient ambulatory after assault on Thursday as per patient. Patient came in by ambulance. Patient stating that he woke up here this morning and wasn’t able to feel anything and unable to move his limbs. Patient has no sensation below the xiphoid process and below mid bicep on his arms bilaterally. Patient able to shrug his shoulders but nothing below. Patient has no reflex to pain or sensation to BLE. Rectal tone checked by Dr. Resident, patient turned while maintaining full spinal precautions. Per MD, no rectal tone noted. Pulses palpable to all extremities 2+, cap refill <3 seconds, all extremities warm to touch. Patient pending MRI and Neurosurgery consult. Will continue to monitor patient.

PATIENT WAS ULTIMATELY ADMITTED TO NEUROSURGICAL SERVICE. HOWEVER, THERE WAS NO DOCUMENTATION THAT ED TEAM SPOKE WITH CONSULTING SERVICE AND TRANSFERRED CARE TO ADMITTING TEAM.

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Summary Recommendations and Pearls and Pitfalls

Emergency personnel routinely encounter intoxicated patients or otherwise altered/psychotic patients, and as a result, may become lax in performing a thorough physical examination including neurological assessment of these patients. Our unconscious biases can lead to haphazard history taking and physical examinations because this patient is like the 1000’s of others I have seen with no problems other than that they should have gotten drunk at home. All patients with altered mental status must have a thorough neurological exam documented at some point in the visit. At a minimum, your neurological examination should include an assessment of cranial nerves, strength, sensation to light touch (or pinprick), and gait. No one will ever fault you for doing too much. Deep tendon reflexes, Romberg, finger-to-nose, proprioception etc. may be indicated depending on the patient’s history. All patients with a psychiatric diagnosis including Suicidal ideation/Homicidal ideation/Audio or visual hallucinations/Psychosis should have a thorough neurological exam documented. Consider including posterior column examination when neurosyphilis is a consideration. All patients with a neurological complaint including headache, weakness, dizziness, lightheadedness, etc., must have a thorough neurological exam documented. It is okay to note that a patient is not being cooperative with a neurological exam and to document what you are actually able to witness during your initial assessment. Generally, the easiest part of the neuro exam is to see that the patient is moving all extremities. However, you must at some point complete the full neuro exam including gait. Patients must be able to walk under their own power before they may be safely discharged home. Remember the NEXUS criteria for patients found down/acutely intoxicated. BE CAREFUL WITH PRE-FORMATTED PHYSICAL EXAM TEMPLATES THAT ARE NOW POPULAR ON MOST ELECTRONIC MEDICAL RECORD PROGRAMS AS A TIME-SAVING MEASURE BECAUSE INCONSISTENCIES CAN BE DAMNING AND LEAD OTHERS TO QUESTION WHETHER YOU TRULY EXAMINED THE PATIENT AT ALL. You should routinely review all RN notes and if there is a discrepancy between what they write and what you were told/saw etc, document it. This includes additional complaints like chest pain, abdominal pain, shoulder pain, weakness, etc. Vital signs are VITAL. Any and all vital sign abnormalities must be addressed. Remember to reassess and refine your differential diagnosis and medical decision-making based on the evidence available to you.

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