Just as the law does not require a physician to deliver a mini-course in medicine when discussing options and risks with a patient, juries will not expect that every nuance of the original event will be captured on the charted page.
But electronic chart narratives containing standard, generalized phraseology will bear poor witness in a subsequent dispute over medical care.
A 91-year-old woman visited Dr. OS, an orthopedic surgeon, after suffering a left femoral neck fracture in a fall. Dr. OS recommended a hemiarthroplasty and discussed the risks, benefits, and alternatives with the patient. The surgery was uneventful and the woman was discharged to a skilled nursing facility (SNF) for rehabilitation.
Nursing notes indicate that 12 days into her tenure at the SNF, the patient had increased confusion and that the surgical incision showed signs of infection, serosanguinous fluid, and some bleeding. When Dr. OS was called with this information, he ordered a seven-day regimen of Keflex.
Lab results showing increasing white blood cell counts were reported to the patient’s attending physician and a urine test showed E. coli. A culture taken from the patient’s hip incision six days after the Keflex order showed staphylococcus aureus. During that period, the patient became more disoriented and complained of increased pain, though there is no indication that Dr. OS was so advised.
The patient and her son visited Dr. OS for the three-week post-op evaluation the day the incision culture was taken. Though Dr. OS’ formatted, typed report shows that the son reported his mother had persistent delirium and was diagnosed with a urinary tract infection, the signed document makes no mention of the Keflex order. Other passages were light on detail, including:
“Past medical history, family history, social history, and review of symptoms were reviewed with the patient and documented in the chart with no changes from the previous visit.”
“Joints, bones, and muscles: Her surgical incision is healing well and no erythema or drainage.”
“I personally reviewed with the patient the radiographs of the left hip from the skilled nursing facility. This demonstrates well-positioned hip hemiarthroplasty with no sign of implant complication or loosening.”
“I had a lengthy discussion with [the patient] regarding the natural history of this condition, the multiple treatment options, and the risks and morbidity of the various treatment options and the condition itself.”
At that visit, Dr. OS wrote that he will see the patient back in four weeks with repeat radiographs and that he will order the staples be replaced with Steri-Strips.
The next morning, the staff at the SNF attempted to remove the staples but encountered heavy drainage. Nursing staff calls early that afternoon were unsuccessful in reaching Dr. OS. A nurse at the office offered the opportunity to speak to another orthopedic surgeon but otherwise recommended contacting the patient’s attending physician. The patient was admitted to the hospital that evening with purulent drainage from the incision. Her condition deteriorated rapidly and she died two days later. The death certificate listed sepsis of the left femoral fracture as a significant contributor to the patient’s death.
In the family’s claim against Dr. OS, the son insisted that in the post-op visit, his mother was in pain and that Dr. OS never looked at the surgical incision. The family resolved the dispute with Dr. OS prior to litigation.
A patient’s or a family’s account of their medical experiences will often include a vivid description of events. Without a chart that offers its own key details of what actually transpired, prevailing in any ensuing credibility contest will be difficult.
Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to gownby@CAPphysicians.com.