Welcome to medmalreviewer.com! The purpose of this site is to improve doctor’s medical knowledge and documentation by reviewing real-life malpractice cases. These cases are presented in long form, deep dive fashion, published monthly. Each case is broken down into several posts. To see more info about the website, here are links to the About Page and FAQs. Another helpful overview post is the 3 Goals of Documentation. I’ve created a Documentation Template to help doctors write notes that are easy to defend, and a Documentation Rubric to grade notes from malpractice cases.
Special thanks to Jeremy Faust (@jeremyfaust) for peer review of this month’s case.
Home Page
Case 1: Shortness of Breath
Case 2
Post 1: Introduction Pt 1
Post 2: Introduction Pt 2
Post 3: Introduction Pt 3
Post 4: Bad Outcome Pt 1
Post 5: Bad Outcome Pt 2
Post 6: Legal Outcome
Post 7: Documentation Review
Post 8: Medical Review
This is a case of a 36-year-old gentleman who presents to the ED after having had several previous visits in the past few days. He ultimately had 3 visits during which the true cause of his symptoms was not diagnosed.
He initially went to an outside urgent care on 3/25/2014. At that time, he had been having a fever for about 2 weeks, dry cough and body aches. He had not had any ill contacts. There is no record of any workup. Documentation was completed almost completely through check boxes, without any significant narrative portion. There is no medical-decision making section.
He was advised to take Tylenol every 4 hours, ibuprofen every 6 hours, and given discharge instructions for “Bronchitis and Asthma”.
