Legal Pearls: The Importance of Documenting Discharge Information

The patient contacted a plaintiff’s attorney who filed a medical malpractice suit against the physician, alleging that the dressing was applied too tightly, compromising the patient’s circulation in his foot and resulting in gangrene, and that he was not given proper discharge instructions.

When the physician was notified of the suit, he met with the defense attorney provided by his insurance company. The attorney asked him many questions.

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“Did you warn the patient that if he felt that the splint was too tight, he should take it off?” the attorney asked.

“I did,” said the doctor. “And I told him to come back to the emergency department if his foot changed color or the pain increased.”

“Did you document these instructions,” the attorney asked as he flipped through the patient’s medical record.

He paused before replying. “I see so many patients a day,” he told the attorney. “I honestly can’t remember if I documented them, but that would be what I would tell a patient in this situation upon discharge.”

“Here it is,” said the attorney, pointing at some short notes in the patient record. “It says ‘patient told to return to ED if there are changes in foot.’ Did you also tell him that he could remove the splint if it was causing him problems?”

“I believe I told him he should remove it to shower and if it started feeling uncomfortable,” replied the physician.

“Did you provide the patient with these instructions in a written form upon discharge?” asked the attorney.

“No,” said the doctor. “I just told him verbally.”

After almost 5 years of floating around the court system, the case finally went to trial. The plaintiff’s medical experts were critical of the doctor’s failure to provide the patient with written discharge instructions and noted that very little had been written in the patient’s record regarding the instructions. The experts criticized his failure to document a patient evaluation of the splint once it had been placed, although the physician testified that he had conducted such an evaluation but had failed to note it in the patient’s record.

Despite the experts’ criticism of the physician, the jury did not believe that he had breached the standard of care required of him and found for the defense.

What’s the Take Home?

Although the doctor was not found culpable in this case, the experts were critical of his instructions to the patient. The old adage “if it’s not in writing, it never happened,” often holds true in these cases. Patient records should include documentation of discussions with patients regarding their treatment. Not including such documentation can put the clinician at risk if there is a difference in memory about the event.

Documentation should be as specific as possible, and preferably should include time and action-specific directions, such as “if your foot is still hurting by Wednesday, call the office” are better than “come back if your foot doesn’t improve.”

Finally, it is essential to ensure that the patient understands the instructions. Patients absorb information in different ways – some prefer images, some prefer written notes, some learn best by repeating the instructions.

Bottom Line — Do not discharge the patient without being sure that he or she understands and can repeat their plan of care to you. And providing a patient with written discharge instructions in addition to verbal is always preferable.