Bad Outcome 2
The patient was admitted to the hospital. In the hospital several hours later, an MRI of his thoracic spine was ordered. The results of the MRI are shown here: By that time his lower extremities seem to have become completely paralyzed. The MRI shows a spinal cord lesion at the lower thoracic area. Given his […]
Bad Outcome
The patient returned to the Emergency Department on 4/2/2014. That morning, he developed new onset of weakness of his bilateral legs. He also developed sensory deficits. The ER documentation from this return visit is unavailable. The physician ordered an MRI of his lumbar spine to rule out cauda equina syndrome, results are shown below. The […]
Case 2: Fever pt 3
Several days later, the patient returned to the same Emergency Department. His primary symptoms seem to now primarily focus on the back pain. “Spine pain” and “neck pain” are both mentioned. Documentation reveals that the fever has now resolved. He has been having a slight headache. Labs were rechecked, showing an improvement in his platelet […]
Case 2: Fever pt 2
Unfortunately, his symptoms continued, and he followed up in an Emergency Department 2 days later on 3/27/2014. He was still having cough and fever, now with neck stiffness and back pain. He had some urinary discomfort that improved. He had a metallic taste in his mouth and slight blurred vision. The documentation also notes that […]
Case 2: Fever
Special thanks to Jeremy Faust (@jeremyfaust) for peer review of this month’s case. 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 […]
Nursing Documentation
Nursing assessment and documentation is a critical part of any ED visit. Nurses are often able to elicit useful information that may have been overlooked. It is always a wise idea to review their documentation. Here is the nursing note for this patient: Also note the patient’s vital signs at discharge. His heart rate was […]
SOB – Jury Instructions
Return to Post 3: Legal Outcome
Template Explanation
Now that we’ve had a basic introduction to the documentation template, we’ll go through each section to illustrate some details and explain the importance. If you want to go back and review the template overview, click here. Lets jump right in: The first section is a simple introduction to the patient and their presentation to […]
Goals of Documentation
The ultimate reason to document is to communicate. While this seems like a fairly obvious statement, it has wide-ranging implications. Communication is at the core of everything we do as EM doctors: communicating with patients guides us towards a diagnosis, communicating with nurses helps us see things we missed and implement team-based care, communicating […]
SOB – Medical Review
We spent the last post focusing on reviewing the documentation, now we can turn our attention to the medical decisions. We’ll spend the first part addressing the decisions made by the first doctor when the PE was missed, and the second part addressing the decisions made during the visit 18 days later when the patient […]