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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Charting: Less is More!

All of us were taught in nursing school “If you didn’t chart it, it didn’t happen.” That is fine as a RN. You have little liability. If you administered a drug, you should have documented it. If you turned over a bed bound patient, you should have documented it. But what does that mean for the nurse practitioner?

Lets first use the reverse logic on that statement, “If you charted it, it happened.” Your chart is the record of what happened. Plain and simple. Whatever you chart, happened… Therefore, whatever you chart is an essential legal document used during litigation and court proceedings against you. IT IS THE RECORD USED DURING THE LEGAL PROCESS.

This is a vital concept to understand. Whatever you put in your chart, happened. Case closed…. If it is documented, IT HAPPENED. So, as a nurse practitioner it is very very very important you think before you type into an EMR.

In the old school days, doctors would write on a paper chart. That chart was filed in a cabinet and only looked at again during follow up visits. The only other time it might have been looked at was during an insurance audit or when a lawyer wanted to review the chart for their client.

What is different now vs then? The doctor could add or remove information to that chart to cover their ass if they were being sued. This is unethical of course, but it happened and happened more often than you think. Paper and a pencil afforded you different options.

In the modern era, this is impossible because EMR charts are locked. When you sign off on a chart in an EMR, that chart is locked for eternity, it can never be edited. THIS IS ANOTHER IMPORTANT CONCEPT YOU NEED TO UNDERSTAND.

You better be 100% sure you want that chart to be locked for eternity before you sign off on it in an EMR. It will be used against you if an adverse event was to happen. An EMR is a medical liability. Addendum’s added to a chart look bad if your chart was ever reviewed. A good old fashion paper chart could look much better!

Regardless, you need to understand this concept. So, the pertinent question here is:

Should you chart more or less?

My personal opinion is LESS. When it comes to charting, LESS IS MORE. I am sure many reading this have reviewed seasoned emergency or internal medicine physician charts. Have you noticed that most of their charts are very short and to the point? Have you ever wondered why?

ITS BECAUSE THEY KNOW THAT THE MORE YOU HAVE IN A MEDICAL CHART, THE MORE THAT A LAWYER CAN USE AGAINST YOU!

This is a paramount concept to understand if you want to cover your ass. LESS IS MORE!

DON’T ASK THE QUESTIONS YOU DON’T WANT THE ANSWERS TOO!

Let me repeat that again.

DON’T ASK THE QUESTIONS YOU DON’T WANT THE ANSWERS TOO!

There was a nurse practitioner a few years back that was sued. This nurse practitioner was working in an urgent care setting and saw an early 20-year-old male. This male was complaining of a productive cough, fever, congestion, rhinorrhea, wheezing, sore throat, and chest pain for 3 days. The patient looked fair with normal vital signs. He presented with text book bronchitis and upper respiratory infection symptoms. She diagnosed the patient with bronchitis and prescribed him azithromycin and an albuterol inhaler. The patient died 2 days later of endocarditis and the family sued the nurse practitioner for medical negligence… she missed the diagnosis.

Guess what? The family won. The settlement was for the max amount of her malpractice policy which was north of 1 million dollars. Her career was over… Having a settlement like this on your record makes you uninsurable which means you are unemployable. Your only option at that point is owning a cash practice. Which is what you should have anyways…

What was the deciding factor in the lawsuit? She documented CHEST PAIN in her record. The plaintiffs lawyer stated that she should have done an ECG on the patient because he was complaining of chest pain. The lawyer stated that the endocarditis would have been picked up and would have saved his life! That is debatable…. But have you ever worked urgent care? EVERYONE COMPLAINS OF CHEST PAIN WITH BRONCHITIS! So now you are supposed to do an ECG on every single person who complains of chest pain and cough? That is ridiculous!

If she would have done an ECG, would it have made a difference in the patient’s outcome? POSSIBLY. She might have picked up on his condition on the ECG or it could have been totally normal… Who knows?

Everyone has chest pain with bronchitis. We hear this complaint multiple times a day in the urgent care setting. This patient had multiple upper respiratory infection symptoms and looked fair at presentation. You see dozens of these patients a day!

So, would she have been able to defend herself successfully if she not had documented chest pain in the record? PROBABLY. She documented to much information… It is what ruined her career…

DON’T ASK THE QUESTIONS YOU DON’T WANT THE ANSWERS TOO!

If you document a complaint, exam finding, vital sign, or a lab result, you better back it up. If you don’t, you are negligible.

She documented chest pain and did not do an ECG. This was the deciding factor in the malpractice case.

So, LESS IS MORE! Do not document a damn story. The more you put in a chart; the more can be used against you.

Follow the suit of the seasoned emergency room doctor whose chart is straight to the point and short. They understand that the more documentation you have, the more can be nitpicked by a lawyer to sue you.

Death happens. Disabilities happen. We live in a real world and real life is unfair and deadly. SHIT HAPPENS. Practice good medicine but protect yourself because the dice sometimes roll the wrong way and there is nothing you can do about it. Anyone who saw this patient would have likely missed the diagnosis and been sued.

This is going against the normal nursing educational grain, I know… But you must understand this concept. Break out of the standard nursing mindset. It does you no favors in the real world. If you want to protect yourself and your family, you better be damn careful with what you type into an EMR.

15 Responses

    1. Curious your thoughts on EPROs? I work for a large academic health center that mandates pts in our specialty fill out an ipad questionnaire self assessment ROS. Ive been saying for a long time this is opening up liability. What are your thoughts/suggestions on electronic ROS vs verbal?

      1. Oh jeez… An electronic ROS questionnaire that the patients fill out? Yes, that opens you up tremendously. It is like school physicals that teens fill out, they answer yes to “numbness in extremities” all the time and it is just when there legs fall asleep in the morning haha. Regardless, yes, I would not be happy if that was mandated.

  1. So don’t include certain pertinent negatives?

    And if we don’t ask about chest pain, the lawyer will say “why didn’t you ask about it”, no?

    1. Don’t ask the questions you don’t want the answers too. Do you really want to know if someone with bronchitis has chest pain? Should you get a d-dimer on every single person who complains of chest pain? Do you get a CT and an ECG on everyone that complains of dizziness? Do you spinal tap everyone who complains of neck stiffness and a headache? If the patient didn’t tell you about a complaint, then you don’t need to address it when it is not pertinent to their chief complaint. But if you document chest pain for bronchitis and did not address it, if something happens, you have no legal defense. Does that make sense?

  2. I really enjoy reading your blog. NPs have needed someone like you. Thanks for sharing your thoughts and advice!

  3. This is very thought provoking – so give an example of how you would have documented this situation to avoid a legal quagmire .

    1. Patient complains of congestion, fever, rhinorrhea, cough, and chest pain when coughing. Chest pain only occurs when coughing. Chest pain is reproducible. Chest pain is non exertional. No pain at present. If you cover yourself, then you are fine. If you just document chest pain and never address it again, then you are screwed. Therefore, DO NOT ASK THE QUESTIONS YOU DO NOT WANT THE ANSWERS TOO. If you document it, you better back it up.

  4. I am interested in a solution to this situation. I first thought, was chest pain variable with inspiration, but which is consistent with bronchitis, but then liability would be, why not a scan for PE ? I am in psychiatry, not physical medicine. But this shared post, increased my nursing culture anxiety since training in the 70’s the nurse is usually and fault and practices with a guilt ridden stress to be perfect. Back then, we were oriented to hospital positions with the infamous patient falling off a stretcher and dying because the bed rail was down. It has only increased my documentation to a higher, time consuming level. . such as whenever I write chest pain, psychiatrically I document cardiac workup in ER negative, and in the present are there other symptoms of anxiety, verses common causes.
    I appreciate this discussion so very much.

  5. Do you think wording matter? For example in your chest pain case above: what if the NP would have documented chest “discomfort” or “pleuritic chest pain” or “chest pressure”. I see charts all the time that dance around the “chest pain” with other words but I don’t know that the liability would be any different… thoughts?

    1. I do not think it would make a difference. Discomfort and chest pressure can easily be cardiac related still. Pleuritic chest pain is likely respiratory in nature. I think you just need to be very careful with what you document in general. Think about the worse case scenario associated with that complaint and rule it out.

  6. The patient in fact did have endocarditis, died, and had reported chest pain. The NP was sued for a missed diagnosis, which is what it was. We don’t have enough information to know if others would have missed this dx or not. Your point is that you should not document chest pain at all when it is a reported symptom, or that you should not document it unless you are prepared to chase it more? This case is much less about documentation and more about what we should do about a symptom that could be serious or could be nothing, and our responsibility to convince ourselves that it isn’t something more serious…like endocarditis. I don’t this missed diagnosis should be used as an example of how to document judiciously.

    1. Do not document it unless you are willing to chase it more. Again, don’t ask the questions you don’t want the answers too. The deciding factor in the lawsuit was because the NP did not do an ECG. Would this have been the case if chest pain was never documented?

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