The Art of the Chart Part 2

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.  

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Jannah Amiel: Okay, so one of the things then I have a question about, because this is what I’m thinking about as you’re talking, I hear in the back of my head, ‘if you didn’t chart it, it didn’t happen,’ right? Like, and that’s, I know that’s a hard and fast drill. I learned it in nursing school. I still hear it.  

I still hear it through, you know, everywhere, every nurse that I ever come across, we kind of still have this same trauma that we all carry around. And there’s a part of me that I feel, yes, like that’s true. If you didn’t chart it, then how in the world could you ever prove that it ever happened? Right?  

If I was the NP, that’s-I want to say on trial, but that doesn’t sound right. But if I was the NP, you know, that’s in front of this case, trying to say, ‘No, I did this. I did this. I guess it’s not on the chart, but I do remember, you know, that I did it.’ It almost feels like where’s the grace, right?  

There is a really realistic way on how this happens, like how you really do chart and how this occurs. But yes, there’s a whole safety aspect that we must be cognizant about our charting, must be good with our charting and complete and thorough. But like, how does that actually show up in real life? That whole, ‘if you didn’t chart it, it didn’t happen.’ I imagine attorneys tell you that all the time. I’m just going to tell you, I imagine attorneys use that line all the time.  

Sally Miller: So, I do-one attorney asked me during a deposition exactly that question. He said, “Are you familiar with the phrase ‘if you didn’t chart it, didn’t happen?’” And I said, “Yes, I am.”  

And he said, “Well, what do you think about that?” And I said, “Whoever said that doesn’t take care of patients.” Really, whoever said that is the pure academic, you know, and because that’s the truth. Whoever said that doesn’t really go through the day-to-day of trying to chart every single thing you do.  

There’s like, there’s the ideal way and then there’s the real way. And then there is the deviation from standard of care. And so, since the issue with malpractice actions is always about the standard of care, it’s not about the ideal. The NP isn’t held to an ideal. I mean, we all personally hold ourselves to that ideal, but that’s not the legal standard. The standard of care is the same or similarly licensed professional would do in the same or similar circumstances.  

And it’s very common that there are things that we don’t chart or we forget to chart sometimes. I mean, we’re just human and that’s the nature of the job. And so there is an allowance for that. 

I mean, there is an allowance for humanity. And there’s two things that we can look at to protect ourselves there. One of them is that it is very appropriate in a deposition to say, “I didn’t chart it, but I did it. I know I did it.” Either like, ‘I remember that patient, I remember that circumstance and I did that.’ And deposition testimony is sworn testimony.  

And sometimes I actually think that that’s more useful because that’s-I mean, it can go either way. Sometimes it seems more useful because if the person really remembers that they did or didn’t do something, they have a clear memory of-like you’re getting their impression right then.  

It made enough of an impression on them that they remembered the circumstance and they can tell you what they did or didn’t do. And it is sworn testimony. And it’s one of the things that juries consider in making their decision.  

So, there’s that. And then the other thing is that even if you don’t remember, but you know it’s your custom and habit or your custom and practice, that’s a common phrase in this business of testimony and legal interviews or documentations that someone can testify as to their ‘custom and practice.’ So, the chart says I didn’t order this test, but it would be my custom and practice in that circumstance to do so. So, I always do that. So, a test might not be the best example because the test result is usually there. 

JA: Okay, like you just kind of always do that. 

SM: But you might say, like, ‘I gave a verbal order-’ It would be-you might say, ‘I gave a verbal order and it was never reported. Well, it would be my custom in practice to do that. And I don’t know why it wasn’t recorded and carried out.’ You know, it may be that the NP gave an order to, you know, the bedside nurse or to whomever.  

And that person, for whatever reason, didn’t record it, didn’t understand it, didn’t carry it out. And then of course, then looking at the NP, ‘Well, why didn’t you order this thing?’ And it’s appropriate to say, ‘It would be, I don’t remember the case, the patient, I don’t remember the case, but it would be in my custom practice to do it.’ And that’s an acceptable and appropriate response. It is, and there really-it really is important to emphasize the difference between the ideal approach versus the real world, what another NP would do in the same or similar circumstances. 

JA: That’s interesting. Yeah. And I wonder like, does the type of charting make a difference? Like, I’m saying back in the day, and now I feel like super old now saying this, you know, like narrative charting versus when EMRs came along, right? And it’s like, click, click, click, click, click, click, click.  

I mean, it was easy. It was great. Cause like you’re in and out. Like I can just click what was weird and wrong. I don’t have to do anything more detailed than that. But I wonder if there’s a difference from a legal perspective, like we chart by exception. So, only talk about the things that are wonky, right? That are awkward, off, not normal. Or you have the very narrative, this is a story and I’m sitting down what feels like 10 minutes reading this whole entire chart. And like, is there a safer charting?  

Like one of those are safer than the other, or do you see more of one type of charting versus the other in these types of cases? 

SM: Well, it’s funny when you say you feel ancient. When I first learned how to chart, we chiseled hieroglyphics on a stone pad. 

JA: Ha ha! 

SM: So, I can totally identify with the sentiment. Much more often now for the NP role, you see charting by exception. Bedside nursing even because everything has become electronic now, that bedside nursing is more click and pick menu than it used to be. I mean, it used to be that the bedside nurse wrote these long narratives, these long nursing notes, and then the NP would-I mean, charting by exception, really is a SOAP note because a SOAP note is just supposed to give you what’s relevant.  

Listen, this is just an opinion. I don’t know that there’s any, you know, any great, authoritative reference that would support one opinion or the other, but I think as a rule, the less we write, the better. I mean, the more you write, the more it’s subject to interpretation and being picked apart, you- 

So, I think the less the better, but the key there to charting by exception is to remember that both pertinent positives and pertinent negatives need to be there. So, it’s not just like, if the patient comes in with chest pain, it’s not just the pertinent positives, it’s not like the EKG changes or the presence of cardiac enzymes. It would also be, like if the enzymes were negative, you would chart that. 

But it’s also the presence or absence of radiation or the presence or absence of nausea and vomiting so common with the inferior wall MI. If you do an abdominal exam, the presence or absence of rebound tenderness is important to note, not just the presence of it. So, I’m trying to put together a good example on the fly here. Maybe if a patient comes in with lower abdominal discomfort- 

JA: Yeah, that makes sense.  

SM: And you do a history and it’s sounding like the pain’s in the right lower quadrant and you examine the abdomen and you don’t appreciate any rebound tenderness. So, you don’t put anything about it in your note. If you appreciated rebound, you would document it positive rebound tenderness. And then you would know it was likely a surgical abdomen and you know, go forward.  

But the absence of rebound tenderness is just as important to document because if when you examine the patient the abdominal exam is benign or non-contributory or no appreciable findings, no rebound tenderness, and you don’t chart that. And then of course there are appendix perfs in 6 hours and they get sepsis and die. It really supports your disposition of that patient.  

You see the patient in the office and they say “my abdomen hurts” and maybe “I’m constipated” or whatever, and you do an exam and the exam is normal. And there’s nothing to really concern you, you’re gonna send them home with a plan that says, ‘if it gets worse, come back,’ but you’re gonna send them home.  

But then if they wind up in the ER that night with a perfed appendix and they go into septic shock, of course, in a couple of years, a bunch of people are gonna be looking at your note and it really goes a long way that you documented the absence of rebound tenderness in a situation like that.  

So charting by exception, I definitely think it focuses us more on what matters. 

JA: Yeah. 

SM: The thing about the narrative, always takes me back to that general impression of the more people talk, the less they say. You talk a lot-I say this as I’m talking a lot-we talk a lot when we’re not really sure what we’re talking about. So, we just try to say everything and hope that something’s right. And it’s just like raising a teenager, you know, when you say, ‘Where were you last night?’ 

‘Well, Mom, you wouldn’t believe it. Well, first we started off here. I mean, we’re just going to study there and everything. But then so-and-so said they were so thirsty and they can’t stay without being thirsty. So, then we had to go to the store to get soda.’  

You know, like, you know, it’s a lie. There’s lie in there. Something they don’t want to tell you. Where if you say, ‘Where were you last night?’ ‘Like, oh, went to Jack’s. I know you don’t like it, but that’s where I was.’  

So, I just feel like the more-I mean, I’ve heard that principle so many times and I wrote my dissertation. My dissertation chair said it was not allowed to be more than 100 pages. 

Because if I didn’t know it well enough to be concise, I didn’t know it well enough to write about it. You know, interesting. I really have held onto that as a teacher. So, same thing like on your notes. If you’re not sure what’s going on, we get these. And it’s a holdover from bedside nursing where we’re taught to write these big, long, flowery things.  

But I think we’re best-served to stick with what matters. just keep in mind that the pertinent negatives are as important as the pertinent positives. 

JA: Yeah, I’d never thought about that. And I think, mean, quite honestly, sometimes I feel like my brain got rewired to like the clicking, you know, so it’s like, you only are looking for the things 

that are the abnormal stuff, but you’re like, you’re not kind of covering the fact that, yes, I recognize that this could have been X, I checked for X, it’s not, you know, like, it doesn’t have any of these signs.  

That’s actually a really good point. What about, you know, in your experience, some of the things that we talked about, we talked about so many good charting tips, but has there been any things that float to the top for you and your expert witness experience as like, these are the really common mistakes that I see in documentation or charting.  

These are the common pitfalls that have occurred that have really played a role in this practice-in this medical malpractice case rather. This charting error or this charting omission or this charting mistake, really made a big difference in the case. 

SM: The things that come immediately to mind, I mean, one-and it’s just, it’s so unique to NPs. I really have never seen this. I mean, I don’t serve as a witness for physician care, but in the course of going over charts, I read all of it. So, I see the physician notes and I see the NP notes. 

And NPs do this way more than physicians: is documenting that you don’t really want to do what you’re doing, but you’re doing it because the patient wants it.  

JA: That sounds bad. 

SM: It’s not good. You really don’t want to write a note-and listen, it’s not as like, my God, as it sounds. I swear, I almost did it yesterday. I almost did it yesterday. And I was laughing at myself when I realized it going, ‘I’m this expert. Look what you’re getting ready to do.’ Again, it’s that different perspective we come from. And I think we try very often to be more accommodating. 

JA: Yeah. 

SM: You know, the physician was raised in the world of, ‘I am the expert, you are the layperson, I tell you what to do and you need to do it.’ And we’re supposed to be getting away from that, it’s shared decision-making. And so, it is appropriate to dialogue with a patient and say, these are options, you know, here’s good and bad of each, this is what I think, you know, but what do you think? That’s very appropriate and that’s what we should do. 

But at the end of the day, you don’t wanna do something that you think is wrong and you don’t wanna document that you did something you think is wrong. And I do see that. I’ve seen that where, in fact, this is another case. I don’t know if we ever talked about it. If not, I’m sure we’ll talk about it next time. But this patient had had back pain for a very long time and a couple of different visits over a period of a year or two. And the patient kept coming in and then at one point the NP suggested an MRI and the patient didn’t want to do that.  

The patient wanted to try physical therapy first. So, the NP was like, ‘Okay, so she writes in her note, you know, that the patient wants to try physical therapy.’ So, they didn’t do the MRI. And of course there was like this big cancerous tumor back there. I think we did talk about her.  

JA: Yeah. Yeah, we did. 

SM: So, you know, I mean, you know, like we’ve said: you can’t force somebody to do what they don’t want to do, 

You don’t document that you know this isn’t right, but you’re doing it because the patient said. There was another circumstance, they always come to mind earlier on than when I have to like regurgitate them here. I can’t think of it. But NPs do that. They document that, ‘Well, this wasn’t really what I thought was right, but the patient wanted it.’ Yeah, yesterday when I was, you know, it was one of those days, everything was taking too long. 

JA: Ha! 

SM: Of course, trying to multitask. We were emailing back and forth between patients about today, and I was trying to do more than I should have. And I had this one circumstance where it just wasn’t clear cut. It wasn’t a clear cut diagnosis. It could have been a couple of different things, and this was like the third visit, and we had been going back and forth a little bit about this is what’s more likely, this is what’s less likely, and it was shared decision-making. Here’s what I think, what do you think? Let’s come up with a plan. 

And it wasn’t a case of, I didn’t think it was the right thing to do. I was really on the fence about where to go. And the patient had a preference that I could live with. So, that’s what I was trying to chart. And I do practice what I preach. At the end, I go back and read my whole note from top to bottom before I sign it. And when I read it, I thought, ‘No, I don’t want to say this this way, because it sounds like it’s the patient’s idea and not mine.’ 

JA: Yeah. 

SM: And it just, didn’t read well and it wouldn’t have read well if somebody was going-and it didn’t really reflect what I was trying to do. It’s just that that’s what happens sometimes when we’re in a hurry and try to rattle through stuff. Yeah, documenting that you know you’re doing the wrong thing and doing it anyway, that’s not a good plan. And then, I mean, the other things, failure to have a follow-up, failure to instruct the patient about follow-up. I do see that a lot. 

JA: Mm -hmm. 

SM: If we see a thing and we think, ‘It’s probably fine,’ you know, but-and we tell the patient, ‘It’s probably fine.’ And you might even say, ‘But if this happens, come back.’ But if it’s not written down, then of course that’s a real sticking point. Like, well, how was the patient supposed to know that they were supposed to follow up?  

So, really the biggest things always seems to come down to that a complaint wasn’t properly evaluated. And proper doesn’t mean exhaustive. It just means some key things were missing in the evaluation and then not having a follow-up plan or not documenting a follow-up plan and documenting the wrong thing. Those are the things I think probably come up most often. 

JA: And those are big deals. Those are big ones. But you know, on the flip of that, like in the flip of charting, like, I don’t love this idea, but the patient wants to, so we’re going to go for it 

see what happens. But on the flip of that, if, the patient is not, you know, they’re not aligned with the recommendation that you’re making, they’re just outright saying, ‘No, I’m not going to do that.’  

Is it appropriate for you to say, you know, ‘I advise patient of X, Y, Z. Patient refused us to do this. I educated them on the consequences. You know, that could happen, but they still choose not to.’ Like, is that appropriate? 

SM: It’s a must do. Yeah, it’s a must do because that does happen. I’ve seen a couple of those with mammograms where a patient was advised to have a mammogram but didn’t want to. Or maybe the patient had a mammogram with an unequivocal result or something that just required ultrasound or follow-up and the patient didn’t want to do it. And that’s no discussion. If the patient doesn’t want to do it, of course you can’t force the patient to, but you do want to be really clear on the consequences and what you advise.  

You hear a lot of them, at least I’ve heard a lot of, you know, my mother used to get mammograms every year and they always told her she was fine and then she got cancer. So why even bother? Like I’m not going to get one because it didn’t find it for her. So, if the patient doesn’t want to have a mammogram, you know, we can’t tie him down and do it. But we document that we advised and they refused.  

Or on the other hand, I’ve had patients say, ‘Yeah, you know my friend she had a mammogram and then they said they found something and then she had to go have a biopsy and it was really hard and she got infected and there was this big hole and then it turned out to be negative. So I’m not doing that. I mean people’s exposures and experiences are really strong drivers of how they seek healthcare and that’s just the way it’s going to be. But again all we can do is is reinforce the point and tell them what we think and if they don’t want to do it, document it that way.  

Yeah, 100%. Yeah, there’s a difference between shared decision-making versus they flat out really just refuse to do what you advise. And also sometimes we just have to tell people, can’t treat you in this circumstance. Yesterday was one of those rough days and I had a patient I had seen several times and she has a personality disorder and she needs a therapist. She must have a therapist. 

JA: Yeah. 

SM: I can’t help her without a therapist. And she keeps coming back to me looking for a pill because it’s a pill society. The first time I let her make the second appointment and we had this 

conversation again and I said, no pills, no pills till you see a therapist. I don’t think a pill is for you. And then yesterday she kept assaulting the office staff trying to make an appointment. The poor office staff, like they’re sending me emails going- 

JA: No! 

SM: ‘Sally, I’m so sorry to bother you with this, but this patient really wants to make an appointment.’ I said,‘ Here, I’m going to type this. Copy and paste it back to her. No appointment until after you see a therapist and I have seen the therapist’s notes, then we can make another appointment.’ So, you know, believe me, she’ll find somebody to see her and give her pills, but it’s not going to be me because it’s just not the thing to do now. 

JA: Yeah, that’s unfortunate. Man. Wow, this was really, really good advice. So, then what would be your one takeaway to our listeners who so far have heard a bunch of cases, and I’ve really enjoyed that. So, big shout out to our listeners.  

And now giving them some advice on documentation, you know, if there can be just one takeaway to say like, ‘Hey, it’s all right, you got this, NP, you got this, but just make sure that you think about this every time you’re documenting and every time you sign off on your chart. Just keep this one thing in mind before you do that.’  

What would that be? 

SM: Write that note as if 2 years from now, five experts are going to spend hours digging it apart. 

JA: Mmm. Dang. 

SM: That’s how I write my notes. I do-I go back. I don’t, you know, I’m fortunate that I can schedule my clinical day because it’s a contract thing. So, I see however many I want or not want and I schedule and I’m mostly in mental health now, but I schedule my new patients at an hour and my follow-ups at a half hour.  

And people that do psych full-time are probably going, ‘God, if only! How do you make any money that way?’ Well, I don’t make a million dollars. I’m fortunate that I’m a faculty member, you know, and I have a diverse approach, so I’m not doing that to pay my bills. But my choice is to do it that way, and it’s purposeful so that not only can I actually spend a little time with people, but I always have a solid 5 minutes, if not more, once the patient is no longer there, that I can sit there and structure my note.  

It’s also a good idea to try to individualize it just a little, if you can. It’s not unusual for follow-ups in psych. This month is a lot like last month or 2 months ago or whatever. So, it’s really legit to copy the HPI from the last time and put it here but try to personalize it in just like one sentence, try to find some something today that’s a little bit unique that demonstrates that you actually did pay attention to the patient today and not just cut and paste.  

But I think the big thing is write that note like experts are going to be looking at it with the magnifying glass. 

JA: Yeah. And we learned that they do. I mean, we’ve done enough of these episodes that we learned that they absolutely do. That’s good advice. That’s great. Awesome.  

Dr. Miller, thank you so much always for joining, for having these conversations. This was great.  

A lot of good advice and takeaways from this. So, I appreciate your time and I appreciate everyone who’s listening in, who got some good takeaways. We hope you enjoyed this episode. and listen in for some more drops on Fridays, some more stories, and just some more learnings that we all can take away just to be a little bit safer, a little bit better than we were yesterday.  

So, appreciate your time. Thanks for listening and goodbye for now. 

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.