The Art of the Chart Part 1

Voiceover: Every minute someone’s life takes a terrifying detour not down a dark alley, but into the sterile, bright halls of healing. They walk in seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis.  

Now, before you raise a pitchfork at every white coat you see, let’s be clear this isn’t an indictment. It’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors.  

Welcome to Scrubs and Subpoenas: Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode a cautionary tale, a blueprint for change, a reminder that even in the darkest corners of human error, there’s a light. The light of knowledge, the light of empathy. The light of a future where healthcare becomes not a gamble, but a guarantee.  

So, join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal, not just bodies, but the very system itself.  

Jannah Amiel: Hello and welcome to another episode-a special episode today of Scrubs and Subpoenas: Tales from the Witness Stand. I’m your host, Jannah Amiel, and joining me is Dr. Sally Miller. Dr. Miller, how are you? 

Sally Miller: I’m well, thank you, and you? 

JA: Good, thank you very much. So good to see you guys. The last time I saw you was at AANP, which was very exciting. I didn’t get to tell you-this is funny. I’m glad we’re opening up with this. When we were at AANP, guess who I ran into? A bunch of Scrubs and Subpoenas fans. 

SM: Okay. 

JA: Yeah, it was really awesome. So, I ran into a lot of NPs that were there during the event that listen Scrubs and Subpoenas. They had wonderful things to say about it. Really, really enjoyed the stories. So, that was really exciting to meet some folks. And one of the thing- funny enough, because we’re talking about this today, that we talked about was like, my gosh, those stories, I can’t believe they wrote that; I can’t believe they charted that’ or I can’t believe they didn’t do that. You know, that’s kind of what we do when we have these conversations. So- 

SM: Mm -hmm. 

JA: This episode-actually for those that are listening in, we’re not going to talk about an actual case. Well, we’re going to talk about what a lot of these cases have in common, which was there was something left to be desired about the documentation or something a little bit off 

about that.  

So, that was a really common theme that we had. A really common theme looking at the documentation and maybe something was missing or could have been a little bit better or something came into question. And I think from my perspective, you know, just as a nurse, I know documentation was like beat into my brain about making sure that 

you do that right.  

And all of the terrible things that can happen. So, I really wanted to take the opportunity today to, you know, have some takeaways for all of us from Dr. Sally Miller, really who serves on these cases and can help-kind of help make sense of what is good documentation, what’s bad documentation, what are some of the things that we picked up along the way? So, I’m gonna open up actually with a question for you.  

We just talked about that, right? Like so many of the cases, they have an element of charting. Like there is something involved about the charting. And really when it gets right down to it, when you’re called on these cases, as I understand it, you’re looking at the documentation, you’re looking at the charts and so are attorneys.  

And so I don’t know, like, is there any hard and fast rule about charting? Do this, do this, do this. Don’t do that.  

SM: I don’t know that I could say there’s like a single hard and fast rule. There’s several things I think that we can do to protect ourselves. But just something else for everybody to keep in mind is that by the time these cases actually get to the point where depositions are being taken that are gonna be the basis of any negotiation, will it settle, will it not settle?  

Or I mean-and if it goes to court, that’s actually easily a year or more later. By the time all that happens, most of the time, the NP has absolutely no memory of the patient. Unless something really catastrophic happens right away, it’s just another clinical day.  

And sometimes the defendant doesn’t know that something went wrong until like a couple years later when they’re served with a complaint. Then-I mean, listen, practicing clinicians see anywhere, it depends on the kind of work you do, but at a minimum, maybe if you’re lucky, 10 or 15 patients a day.  

And if you’re in a more fast-paced urgent care, higher-paced kind of environment, you may see 50 patients a day. Go out 2 years before you get served with a complaint, and a lot of times, more often than not, the NP who is the subject of the complaint has no recollection of the patient. 

So, all that there is, is what you wrote down. I read this in depositions more often than not. One of the first questions that the attorneys will ask is, “Do you have any memory of this patient?” You know, “Don’t tell me what you’re reading, but do you have any memory of this patient?” And a lot of times the answer is no. Sometimes there might be a vague memory, a faint memory, but it just makes what’s in writing so much more important.  

So, you’re right. I mean, documentation, that really is what it comes down to in the end. And I mean- 

JA: Wow. 

SM: I have seen massive perseveration over a single sentence, a single line, or a line that’s not 

there. So, I really can’t emphasize the importance of documentation enough. So, while I don’t have one hard and fast rule, number one, I would say, I’m a realist. I mean, I know we’re all taught in school the ideal way. You must chart this, this, this, and this. 

JA: Yes. 

SM: And then you go to work and it’s like, there’s no way that you can write War and Peace for every patient. It’s not gonna happen. So, there’s like the ideal way that we learn in school and then there’s having to adapt it to a fast-paced or even a moderately paced clinical environment.  

So, I know that these things that I will rattle off, it’s hard sometimes to keep them in mind, but there are a couple of things that I think is just helpful to try and approach every chart with. 

JA: Yeah. Yeah. 

SM: One of them is that it really-this sounds so prosaic, but it gets missed a lot. The note, no matter how short it is, and if it’s an acute complaint like a UTI, you know, I’m a 21-year-old woman, I’m healthy, no medical history, but I’ve been having burning urination for 24 hours, the note doesn’t have to be this long, like this. But anybody who picks that up should be able to follow it from start to finish. I mean, this is the basic SOAP format that we teach people. 

Now with electronic charting and click and pick documentation and stuff like that, it’s not like the old days where we wrote the history and physical exam. But the same, the same pattern is still there.  

The chief complaint, a good practice to get into is the chief complaint should be a one liner and it should be in quotes. It should be exactly what the patient said, not your interpretation of what the patient said, but exactly what the patient said because- 

JA: Yes. 

SM: That first-you know, like, and I had an example of this and I kind of lost it that fast. Like one of them that I remember from my own history is the patient was there because his stomach hurt. 

That’s what he said. “His stomach hurt.” In quotes, “my stomach hurts.” That’s the way to write it. 

Because if you start inserting your own interpretation of what that is, it can get easily missed. You know, in the abdomen, there are how many different organs in there? 

JA: Right. 

SM: And there’s radiating pain and stuff. Just one shift. Patient says, “my stomach hurts” and we write “lower abdominal pain.” You can miss it and change stuff entirely. So, I guess I’m sort of going off on a tangent here, but start off with exactly why they’re there. What did they say? Not what you think they said or what you think they mean, but what’s there?  

Because that will keep you focused for the rest of that visit. And then after that chief complaint, the history of present illness has to address the complaint. And I know people are listening to this going, what? I know, I know. But like sometimes it doesn’t. Like I was just reading a chart yesterday. As you know, we were going back and forth about this, you know, we’re talking about today.  

And I was reading this chart where the patient’s chief complaint was headache. But he was there because he had a headache that was so bad for 2 days- 

JA: Yeah. 

SM: And he had gone to the ER and nothing helped. That was his chief complaint. He was there complaining of the headache, but somehow it got transferred to high blood pressure because when the patient went to the ER 2 days prior, he went with a headache. They measured his blood pressure at like 160/94 or something irrelevant. And then they, the ER, attributed the headache to the blood pressure.  

So then, and they advised, if you don’t get any better, go to primary care. So, this patient comes in to establish care with a primary care practice because of this acute headache that I believe was one of the cases we’ve talked about in the past.  

It turned out to be an aneurysm that ruptured and the patient died. I mean, the headache was clearly-by all accounts, the headache was incapacitating and the reason he was there. But if you read this patient’s note, the chief complaint is high blood pressure. 

JA: Yes, I remember that. 

SM: So, we don’t want to-you know, that’s one place where you can miss it. But then, you know, the history of present illness, again, it doesn’t have to be a big long thing, but it really does need to address the chief complaint.  

And it’s interesting sometimes when you look at charts and it doesn’t, like, you know, it might say that they’re there for, has abdominal pain, knee hurts and diabetes. You know, you’ll have three things in the chief complaint. 

Boom, boom, boom. And then the history of present illness doesn’t address the diabetes at all. It focuses on the knee pain. Well, okay, I mean, that’s the problem because from the chief complaint to the history that addresses the complaint, then your physical exam has to further elucidate the history, you know? 

 And that needs to lead to the diagnosis. Like every diagnosis is listed- 

JA: Right, right, that makes sense. 

SM: Should be supported. Should be able to-an independent reader should be able to pick up that chart and say, this diagnosis is because of this, this, and this. And then every diagnosis needs a plan of care and every plan of care needs a follow-up.  

And I know it sounds like forever, but it’s not. I mean, there are some simple basics here. Like one case that I had years ago was about a lady who came to the emergency room with leg pain and swelling. 

And the reason she went right to the emergency room was because her leg pain and swelling seemed exactly like a year ago when she had pain and swelling in her other leg and it turned out to be a DVT. Right?  

So, year one, she has a DVT in one lower extremity. And then she, you know, she gets managed on enoxaparin for a while, whatever. And then a year or two later, the other leg looks just like the first leg. So she goes to the emergency room and she’s seen by a nurse practitioner. 

And the chief complaint is leg pain and swelling. This is good. The history of present illness talks about the leg pain and swelling. The physical examination documents every body system except the leg. I mean, I’m not kidding you. It goes, the head is normocephalic; extraocular muscles are intact; pupils are equal, round, reactive to light and accommodation. Throat is clear without exudate, no palpable nodes, the heart, the lungs, I mean like every other body system, but there’s no exam of the leg.  

And it was hugely important because the next step of course was the diagnostic evaluation where she was sent for an ultrasound of the leg. So, they did an ultrasound, well, they probably came to her and did the ultrasound. They did an ultrasound of the leg that did not support 

a DVT.  

Did not support any thrombus. So, the patient was discharged to home where of course she threw a massive pulmonary embolus and died. In-you know, the NP as the defendant really, really hung the hat on the negative ultrasound. And two problems here are that- 

I mean, this said, we’ve talked about this before too like never hanging your hat on any one diagnostic study. They are one tool. 

JA: Mm -hmm.  

SM: They’re a tool there. They’re not like-they’re not to be all-they’re one tool but in this particular case it was critical to know what the exam of the leg looked like because if the examination of the leg documented a normal extremity, know normal color, normal temp, no discoloration- 

JA: Yes, like anchoring, right? That’s what you call it. Like anchoring. 

SM: If the exam was normal and the ultrasound was normal, well, okay, that’s a defense. Patient had this complaint, but on physical exam, it looked normal, it palpated normal, there was no nothing wrong, and the ultrasound was negative, and so we sent her home.  

And she had an embolus and it was a horrible story, but it would have been a defensible one. On the other hand, if the leg was edematous, tensely swollen, positive calf tenderness like any findings that suggested a DVT, then that negative ultrasound-just that’s not that’s not a defense.  

If the ultrasound is negative, like if the diagnostic study and the physical exam are discordant, then you do the next diagnostic study. Imean, ultrasounds are not invasive. They’re only as good as the ultrasound tech, frankly, and they can be wrong.  

If clinical suspicion is really high based on the physical, and the study doesn’t support it, you go to the next study. So, like in that circumstance, the exam of the leg was enormously important to try to defend the NP and it wasn’t there. And you look at this and say, how do you evaluate a patient with leg pain and swelling and an old DVT and send them off for an ultrasound and not examine the leg?  

But again, there’s those of you that will make mistakes and there’s those of us that have and sometimes you just have a TIA. 

A blonde moment, a senior moment, a TIA, know, pick your synaptic problem. We all have them sometimes. So, these are the little things. I mean, these are the things that do people in. 

So, I would just keep in mind that it doesn’t have to be a big long note, but it really needs to read in a way that an independent reader can take it and follow it from start to finish, you know? And that’s just one example.  

The other thing that really that hurts people sometimes is not documenting a follow-up plan. And again, it can be a one-liner, ‘return to clinic if not improved’, ‘return to clinic if worsens’, ‘return to clinic if X, Y, and Z.’ You might remember we talked about a case where a lady had an ulcer in the genitalia, and it was just one ulcer, and it was diagnosed as HSV, and she was given acyclovir cream. I mean, while that wasn’t the best answer, there was never any follow-up of that. ‘Return if not improved, return if spreads like nothing.’ 

So, even though it sounds like second nature to us, if we don’t tell the patients to follow up, they sometimes think they don’t have to. I mean, in something like that, she might’ve thought, 

she wasn’t worried about it, gave me this cream. So, I don’t know. And to us, we think, ‘How could you think that?’ But, that’s how patients do. You also see things where, like, they might have like a little, you know, a little, naiveness or a little discoloration or something.  

And we see the patient and we do a good exam and we determine that it’s not a suspicious lesion. And, you know, we’re not concerned. It looks like just a benign pigment change or something, but you have to tell the patient if it gets bigger, if it ulcerates, if it this or that, come back and see us.  

And so, not documenting a follow-up plan, even if the follow-up is ‘return if not improved’, ‘return if X, Y, and Z’ happens. So, I know it takes-it just sounds really basic and yet so often we miss it.  

And half the time it’s because we’re in a hurry. The other thing I would encourage anybody to do, if you can, again, I’m a realist. I am very much a realist. So, when I teach CE or whatever, 

I know there’s the textbook perfect way and then there’s what we all do in the day-to-day. So I know this is hard, but if you can structure your day so that you don’t sign off on that note until after you had a minute to review it, where you really paid attention to it.  

Like people that have a 35- or 40-scheduled day and they’re trying to get out and they’re behind and stuff always happens, know, often you’re charting on the-I’m having a TIA myself here. 

Starting on the fly, that’s what I’m trying to say. You’re just, you’re seeing the patient, you’re trying to type and they’re saying stuff and you’re trying to pay attention, but you’re typing 

cause you’re in a hurry. Like try-like either don’t sign the note right then.  

You know, if you can-ideally, if you can structure your day so that you can have even just 2 minutes to yourself when the patient’s out of the room before the next patient comes in, that you can go back to it and really read it from top to bottom one more time before you sign off on it.  

And if you can’t do it then save it till the end of the day. And sometimes it makes for long days like, yeah, there I was yesterday, you know, thinking this very thought like this is one of those days where I just can’t finish my notes till the end of the day.  

You type in as much as you can so that you remember enough to prompt you, but try not to sign off on that note. Like sometimes we’re just in such a hurry to get it done. And some practices they require that you sign it off in X amount of time and all of that. 

And just signing off on it too fast, that’s where stuff gets missed too. So, I know it’s not easy and I know we can’t all do it every time. And whenever I have one of those days, I’m like, ‘God, 

I hope this isn’t the time I get sued.’ I hope this isn’t the time that five experts are reviewing this chart in 2, 3 years, because it happens to all of us sometimes that we don’t take the time, but keep it in the back of your mind. Try to just have a minute or 2 to yourself to look at that note, really concentrate on the note. 

What it says from top to bottom before you submit it. Those are the things I think I would encourage everybody to try to just try to use as a guide. 

JA: I think that’s really good advice, solid advice too. And a couple of times I kind of heard-I think it’s my own brain saying, ‘You didn’t document it, it didn’t happen. If you didn’t chart it, it didn’t happen.’ And I’m curious about your thoughts on that because I feel like personally there’s one side that’s like, ‘Well, that’s true.’ I mean, we all learned if you didn’t document it and there’s no proof that you did whatever it is that you’re trying now to tell an attorney that you actually did. But to your point, very realistic. 

SM: I-sometimes you don’t document everything. You just don’t. And maybe because you forgot, maybe because there was time or something that’s happened. But there’s almost a piece of that that seems, and I hate to say this, but seems unfair. Like, I don’t know that we can be that rigid and say, ‘If you didn’t chart it, it didn’t happen.’ 

But on the other end, like if you’re in a scenario and there’s an empty pleading that like, ‘No, no, I actually did this. And you’re looking saying, ‘Well, I don’t see anywhere in this chart that you did.’ 

Voiceover: Thank you for listening and learning with Scrubs and Subpoenas: Tales from the Witness Stand, presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.