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.
Index Case 8
Cough
Follow-up
Specialty Consult
Tumor Board
Legal
Review
Documentation
This month’s case is about a 63 year old man who went to an urgent care with a cough. The triage note and nursing documentation through discharge are shown below. Note the vitals showing a temperature of 98.4 F, heart rate of 123 bpm, respiratory rate of 15/min, blood pressure of 129/94, and oxygen saturation of 96% on room air.
The physician’s note is shown below.
A chest xray was ordered. The radiologist’s interpretation is shown here:
The rest of the physician’s note is shown below.
The patient was discharged and instructed to follow-up with his primary care provider or back in urgent care.
What do you think the bad outcome will be?
Continue to the next page to see the outcome from this case!
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