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Missing information increases risks of malpractice allegations

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ED Triage and Ongoing Assessment


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ED Triage and Ongoing Assessment

Related to: Cures Act: Opening Notes, Emergency Medicine

  • Can your next patient give a complete, honest, and accurate history? 
  • Will you be able to access her medical records? 
  • Did you get a good hand-off? Does anyone on your shift know her? 
  • Have any of those factors changed during the course of her visit?

Whether you serve a low-volume community hospital or a jam-packed urban teaching center, your population presents a broad diversity of complaints. You hope the patients, from Little Leaguers to octogenarians, can provide context of this visit and their medical history. Often, however, you will need more information from family, records, or colleagues in order to narrow—or broaden—your diagnostic focus.

If insufficiently integrated EMRs leave you prone to missing key clinical information, you must pay extra attention to the symptoms your patient or her family members express the most concern about. This, of course, has to be balanced against co-morbidities and any tendency to focus on a diagnosis you may have initially presumed.

Patients presenting with multiple traumas may draw multiple caregivers, but the poor historian with vague belly pain might demand equal vigilance.

A patient with a significant medical history and affirming symptoms also poses the risk of a plausible answer that may limit your differential diagnosis, even when contrary clues are present.

Increasing volume amplifies the pressure as you and your ED colleagues contend with the slow simmer of patients’ discomfort, persistent distractions, and the queue in the waiting room. Amidst this everyday chaos lies the risk of critical patient information getting lost en route to those of you working to make management decisions and safe dispositions.

Therein, potentially, is the difference between an expertly managed course in the ED or a slightly off-target trajectory ending in harm for patients whose condition changed over time.

Case Example: Assessment

A 49-year-old with a history of hypertension and cardiomyopathy presented to the ED with complaints of eye pain, blurred vision, and unsteady gait since the previous evening. After a limited physical exam, he was sent to the eye clinic for evaluation. Absent radiological studies or neurological consults, the patient was discharged with a diagnosis of corneal abrasion, macular elevation, and hypertension retinopathy. The following day, he returned to the ED with continued blurred vision and headache, and was noted to have altered mental status. CT scan revealed posterior and anterior artery stroke, leaving the patient with permanent visual impairment and cognitive deficits. (Case settled: $2.2M)

July 25, 2012
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