Many of our express care physicians receive the "JUCM", or Journal of Urgent Care Medicine,and the November 2012 issue had an excellent summary article in the "health law" section on malpractice reminders (page 33 in the scroll magazine below, if accessible).
http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2012/1112/
The article written by a MD/JD had several tidbits to keep you from getting complacent in the everyday drone of mucus and aches.
1. Remember, in "drug seekers with recurrent back pain"-stay vigilant for the rare but catastrophic spinal epidural abscess. Per the article fewer than 10% of spinal epidural abscesses present with the textbook triad of back pain, fever, and focal neurological deficits, but if you do see fever and back pain, strongly consider emergent imaging in the ER. As always a thorough neurologic exam is crucial, even with routine back pain.
2. Yes, the "lab book" is the bane of our existence, but consider reminder #3- "failure to inform a patient about an abnormal test is a red flag issue." I think the biggest landmine here is when a chest x-ray to rule out pneumonia shows a nodule, or when the radiologist thinks it is pneumonia, but suggests "repeat x-ray in 6 weeks to confirm clearing." In these cases I strongly suggest, getting a copy of the CD, and writing in the discharge instructions to have a repeat xray in 6-8 weeks to confirm clearing. With a smoker, I would even go so far as writing, "to ensure no tumor is present" in the discharge instructions, which clearly and hopefully unequivocally conveys to the patient the gravitas of the situation.
3.The article has the solid perspective, " Urgent care is a very high risk environment-even higher than the emergency department. It is high risk because everyone, including the patients, thinks it is low risk and we can all be lured into a false sense of complacency. Remember, "(think) Worst First!"
4.If your discharge diagnosis is a diagnosis that may come back to haunt you, such as headache, chest pain, et al, then be very thorough in documenting your reasoning and pertinent positives and negatives. For example, go back to spring 2012 and review the blog article on "When to Refrain with Chest Pain" for some crucial pertinent negatives.
5.Minor head injuries in patients on coumadin are by defintion not minor.
6 Here is a classic, " The same patient presenting more than twice with the same complaint needs to be conclusively figured out/admitted on the third visit." I always try to adhere to a "3 strikes and you are out policy"- the ER comes on strike 3. Every "bounceback" exponentially increases your liability and appearance of ignorance to a jury. Refer and move on. It is hard to "save the world" when embroiled in a major, years long, malpractice battle, so again, move on.
7. Read the notes of others before discharging a patient. Pay close attention to the ED summary note with vitals, as it is easy for the nurses to type in a vital sign wrong- and that typo could make you look incompetent. I have seen legion times a mistyped temperature of 95, or a respiratory rate of 56. You may ignore it since you can see the patient, but it needs to be corrected, as that temperature of 95 will doom you when that elderly patient with what you "think" is manageable pyelonephritis goes home, becomes septic overnight, and dies the next day. Then, the lawyer is suddenly reminding you that hypothermia can signal advanced sepsis....and then we have a major problem. Also read the nurses "chief complaint section" to ensure his/her documentation is not contradicting yours-and write out the resolution. As the article states, you don't want your note to say "mild headache", but the nurse triage note to say, "worst headache of my life." You may state in your medical decision making, " nurse triage note reviewed, discussed with patient directly how severe headache was- patient stated 6/10, and was "throbbing" but "not worst of life." Overlooked discrepancies can hurt you immensely!
Never forget, as a medical provider in today's world you are one thing- a target.
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