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Story
BF was a 44-year-old man with essential hypertension who was admitted to the hospital with intractable low back pain and urinary retention. No antecedent trauma was reported. He was seen in the ED three times in the preceding week for similar complaints. In each case, he had relief with intravenous analgesia, but the symptoms quickly returned.
Prior to his admission he had lumbar radiography as well as an MRI of the lumbar spine. Plain films were unremarkable, but the MRI showed a potentially significant L4-L5 foraminal stenosis on the left and L5-S1 foraminal stenosis on the right. Neurosurgery (NS) reviewed the MRI and did not feel operative intervention was indicated. A bladder catheter was inserted in the ED for urinary retention. He was subsequently admitted to Dr. Hospitalist, who initiated medical treatment. Dr. Hospitalist’s admission impression:
"44 yo with low back pain and sciatica from foraminal stenosis. There is no neurologic compromise. The urinary retention is probably due to narcotic effects. This was discussed with neurosurgery from the ED. The patient will be admitted for observation, pain control, and physical therapy."
The following day, Dr. Hospitalist noted that BF’s pain was controlled but that he had weakness in his left foot. Dr. Hospitalist contacted NS and was reassured that if BF’s symptoms were improving with respect to pain, numbness, and/or weakness, then neurologic compromise was unlikely. Over the next 2 days, Dr. Hospitalist documented subjective improvement in BF’s pain with 4+/5 left lower extremity (LLE) strength.
On hospital day 4, BF was unable to move his legs. Dr. Hospitalist transferred BF later that day to a nearby hospital with on-site NS. An MRI performed there demonstrated a large T9-L5 epidural abscess. Despite emergent neurosurgical decompression, BF remained permanently paralyzed below the umbilicus.
Complaint
BF was naturally distraught with his paralysis. He claimed that he told everyone that he had numbness and weakness in both his legs from the very start and that nobody did anything to help him until it was too late. Expert review of the medical record found the following entries on the day of admission:
RN day note: "Patient complains of bilateral LE numbness, weak plantar, and dorsiflexion of LLE."
Physical therapy note: "Bilateral leg paresthesias from the waist down; absent anterior tibialis motor function; quadriceps weakness on the left."
Occupational therapy note: "Patient has sensation symptoms that are not reported in chart from prior MD evaluation."
Despite daily documentation by Dr. Hospitalist that BF was improving, chart entries by the nursing staff and the therapists on day 2 suggested the opposite.
On day 3, Dr. Hospitalist acknowledged that the low back pain had been better until the previous night. However, the strength was unchanged, and he was "still a little bit numb." A physical therapy note written 1 hour after Dr. Hospitalist examined BF and charted 4+/5 strength reported "slideboard transfers required due to inability to stand."
Scientific principles
Spinal epidural abscess (SEA) requires prompt recognition and proper management to avoid potentially disastrous complications. The classical diagnostic triad consists of fever, spinal pain, and neurologic deficits. Untreated abscesses will cause symptoms that progress in a typical sequence: 1) back pain, which is often focal and severe, 2) root pain, described as "shooting" or "electric shocks" in the distribution of the affected nerve root, 3) motor weakness, sensory changes, and bladder or bowel dysfunction, and then 4) paralysis. Once paralysis develops, it may quickly become irreversible.
Complaint rebuttal and discussion
Defense experts reinforced that SEA was a rare diagnosis and that Dr. Hospitalist appropriately performed a comprehensive admission H+P with a review of all prior ED visits and radiographic studies, and further examined BF daily and discussed BF’s case with a neurosurgical specialist who provided reassurance that no serious spinal pathology existed. Dr. Hospitalist testified that BF’s exam was dependent on patient participation and, although at times inconsistent, it suggested gradual improvement in his condition. Dr. Hospitalist also testified that he was not fully aware of the RN and therapist impressions at the time, but he trusted his own evaluations as being most accurate.
Plaintiff experts had a hard time reconciling the two conflicting stories in the chart. Additional chart review revealed that on day 2, Dr. Hospitalist inexplicably ordered a CRP and ESR that were both elevated (14.5 mg/dL and 80 mm/hr, respectively) but were never mentioned in the progress notes – nor was the rationale for ordering the studies or an impression of the results. Dr. Hospitalist testified he had no memory of ordering the studies. Moreover, the discharge summary authored by Dr. Hospitalist prior to BF transfer was contradictory to his own progress note documentation:
Hospitalist note, day 2: "There is less pain, actually no pain. The numbness or lack of sensation is improved. The ability to move his left leg is also improved; however, it is still difficult to move it and not because of pain."
Discharge summary: "There were no unifying localizing findings to suggest spinal cord compromise, and much of his symptoms may be related to pain. ... there has been no real progress made in terms of controlling his pain."
Taking all the evidence in aggregate, the plaintiff experts were critical that Dr. Hospitalist seemed unaware of the full range of patient symptoms, the laboratory evidence for an inflammatory process, the reliance on a specialist who never examined the patient, and the inadvertent or intentional chart contradictions.
Conclusion
Charting is one of the four "Cs" in reducing medicolegal risk (charting, competence, compassion, and communication). In this case, the charting by Dr. Hospitalist appeared appropriate on the surface, but inadvertently or intentionally hid the entire clinical picture. The difference in documentation between hospitalist and the RN/therapy notes in this case seems hard to explain, but various health care providers may reasonably see and chart diverse findings and impressions. However, the conflicting documentation between several of Dr. Hospitalist’s own notes severely damaged his credibility.
This case was settled for an undisclosed amount in favor of the plaintiff.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read earlier columns online at ehospitalistnews.com/Lessons.
Story
BF was a 44-year-old man with essential hypertension who was admitted to the hospital with intractable low back pain and urinary retention. No antecedent trauma was reported. He was seen in the ED three times in the preceding week for similar complaints. In each case, he had relief with intravenous analgesia, but the symptoms quickly returned.
Prior to his admission he had lumbar radiography as well as an MRI of the lumbar spine. Plain films were unremarkable, but the MRI showed a potentially significant L4-L5 foraminal stenosis on the left and L5-S1 foraminal stenosis on the right. Neurosurgery (NS) reviewed the MRI and did not feel operative intervention was indicated. A bladder catheter was inserted in the ED for urinary retention. He was subsequently admitted to Dr. Hospitalist, who initiated medical treatment. Dr. Hospitalist’s admission impression:
"44 yo with low back pain and sciatica from foraminal stenosis. There is no neurologic compromise. The urinary retention is probably due to narcotic effects. This was discussed with neurosurgery from the ED. The patient will be admitted for observation, pain control, and physical therapy."
The following day, Dr. Hospitalist noted that BF’s pain was controlled but that he had weakness in his left foot. Dr. Hospitalist contacted NS and was reassured that if BF’s symptoms were improving with respect to pain, numbness, and/or weakness, then neurologic compromise was unlikely. Over the next 2 days, Dr. Hospitalist documented subjective improvement in BF’s pain with 4+/5 left lower extremity (LLE) strength.
On hospital day 4, BF was unable to move his legs. Dr. Hospitalist transferred BF later that day to a nearby hospital with on-site NS. An MRI performed there demonstrated a large T9-L5 epidural abscess. Despite emergent neurosurgical decompression, BF remained permanently paralyzed below the umbilicus.
Complaint
BF was naturally distraught with his paralysis. He claimed that he told everyone that he had numbness and weakness in both his legs from the very start and that nobody did anything to help him until it was too late. Expert review of the medical record found the following entries on the day of admission:
RN day note: "Patient complains of bilateral LE numbness, weak plantar, and dorsiflexion of LLE."
Physical therapy note: "Bilateral leg paresthesias from the waist down; absent anterior tibialis motor function; quadriceps weakness on the left."
Occupational therapy note: "Patient has sensation symptoms that are not reported in chart from prior MD evaluation."
Despite daily documentation by Dr. Hospitalist that BF was improving, chart entries by the nursing staff and the therapists on day 2 suggested the opposite.
On day 3, Dr. Hospitalist acknowledged that the low back pain had been better until the previous night. However, the strength was unchanged, and he was "still a little bit numb." A physical therapy note written 1 hour after Dr. Hospitalist examined BF and charted 4+/5 strength reported "slideboard transfers required due to inability to stand."
Scientific principles
Spinal epidural abscess (SEA) requires prompt recognition and proper management to avoid potentially disastrous complications. The classical diagnostic triad consists of fever, spinal pain, and neurologic deficits. Untreated abscesses will cause symptoms that progress in a typical sequence: 1) back pain, which is often focal and severe, 2) root pain, described as "shooting" or "electric shocks" in the distribution of the affected nerve root, 3) motor weakness, sensory changes, and bladder or bowel dysfunction, and then 4) paralysis. Once paralysis develops, it may quickly become irreversible.
Complaint rebuttal and discussion
Defense experts reinforced that SEA was a rare diagnosis and that Dr. Hospitalist appropriately performed a comprehensive admission H+P with a review of all prior ED visits and radiographic studies, and further examined BF daily and discussed BF’s case with a neurosurgical specialist who provided reassurance that no serious spinal pathology existed. Dr. Hospitalist testified that BF’s exam was dependent on patient participation and, although at times inconsistent, it suggested gradual improvement in his condition. Dr. Hospitalist also testified that he was not fully aware of the RN and therapist impressions at the time, but he trusted his own evaluations as being most accurate.
Plaintiff experts had a hard time reconciling the two conflicting stories in the chart. Additional chart review revealed that on day 2, Dr. Hospitalist inexplicably ordered a CRP and ESR that were both elevated (14.5 mg/dL and 80 mm/hr, respectively) but were never mentioned in the progress notes – nor was the rationale for ordering the studies or an impression of the results. Dr. Hospitalist testified he had no memory of ordering the studies. Moreover, the discharge summary authored by Dr. Hospitalist prior to BF transfer was contradictory to his own progress note documentation:
Hospitalist note, day 2: "There is less pain, actually no pain. The numbness or lack of sensation is improved. The ability to move his left leg is also improved; however, it is still difficult to move it and not because of pain."
Discharge summary: "There were no unifying localizing findings to suggest spinal cord compromise, and much of his symptoms may be related to pain. ... there has been no real progress made in terms of controlling his pain."
Taking all the evidence in aggregate, the plaintiff experts were critical that Dr. Hospitalist seemed unaware of the full range of patient symptoms, the laboratory evidence for an inflammatory process, the reliance on a specialist who never examined the patient, and the inadvertent or intentional chart contradictions.
Conclusion
Charting is one of the four "Cs" in reducing medicolegal risk (charting, competence, compassion, and communication). In this case, the charting by Dr. Hospitalist appeared appropriate on the surface, but inadvertently or intentionally hid the entire clinical picture. The difference in documentation between hospitalist and the RN/therapy notes in this case seems hard to explain, but various health care providers may reasonably see and chart diverse findings and impressions. However, the conflicting documentation between several of Dr. Hospitalist’s own notes severely damaged his credibility.
This case was settled for an undisclosed amount in favor of the plaintiff.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read earlier columns online at ehospitalistnews.com/Lessons.
Story
BF was a 44-year-old man with essential hypertension who was admitted to the hospital with intractable low back pain and urinary retention. No antecedent trauma was reported. He was seen in the ED three times in the preceding week for similar complaints. In each case, he had relief with intravenous analgesia, but the symptoms quickly returned.
Prior to his admission he had lumbar radiography as well as an MRI of the lumbar spine. Plain films were unremarkable, but the MRI showed a potentially significant L4-L5 foraminal stenosis on the left and L5-S1 foraminal stenosis on the right. Neurosurgery (NS) reviewed the MRI and did not feel operative intervention was indicated. A bladder catheter was inserted in the ED for urinary retention. He was subsequently admitted to Dr. Hospitalist, who initiated medical treatment. Dr. Hospitalist’s admission impression:
"44 yo with low back pain and sciatica from foraminal stenosis. There is no neurologic compromise. The urinary retention is probably due to narcotic effects. This was discussed with neurosurgery from the ED. The patient will be admitted for observation, pain control, and physical therapy."
The following day, Dr. Hospitalist noted that BF’s pain was controlled but that he had weakness in his left foot. Dr. Hospitalist contacted NS and was reassured that if BF’s symptoms were improving with respect to pain, numbness, and/or weakness, then neurologic compromise was unlikely. Over the next 2 days, Dr. Hospitalist documented subjective improvement in BF’s pain with 4+/5 left lower extremity (LLE) strength.
On hospital day 4, BF was unable to move his legs. Dr. Hospitalist transferred BF later that day to a nearby hospital with on-site NS. An MRI performed there demonstrated a large T9-L5 epidural abscess. Despite emergent neurosurgical decompression, BF remained permanently paralyzed below the umbilicus.
Complaint
BF was naturally distraught with his paralysis. He claimed that he told everyone that he had numbness and weakness in both his legs from the very start and that nobody did anything to help him until it was too late. Expert review of the medical record found the following entries on the day of admission:
RN day note: "Patient complains of bilateral LE numbness, weak plantar, and dorsiflexion of LLE."
Physical therapy note: "Bilateral leg paresthesias from the waist down; absent anterior tibialis motor function; quadriceps weakness on the left."
Occupational therapy note: "Patient has sensation symptoms that are not reported in chart from prior MD evaluation."
Despite daily documentation by Dr. Hospitalist that BF was improving, chart entries by the nursing staff and the therapists on day 2 suggested the opposite.
On day 3, Dr. Hospitalist acknowledged that the low back pain had been better until the previous night. However, the strength was unchanged, and he was "still a little bit numb." A physical therapy note written 1 hour after Dr. Hospitalist examined BF and charted 4+/5 strength reported "slideboard transfers required due to inability to stand."
Scientific principles
Spinal epidural abscess (SEA) requires prompt recognition and proper management to avoid potentially disastrous complications. The classical diagnostic triad consists of fever, spinal pain, and neurologic deficits. Untreated abscesses will cause symptoms that progress in a typical sequence: 1) back pain, which is often focal and severe, 2) root pain, described as "shooting" or "electric shocks" in the distribution of the affected nerve root, 3) motor weakness, sensory changes, and bladder or bowel dysfunction, and then 4) paralysis. Once paralysis develops, it may quickly become irreversible.
Complaint rebuttal and discussion
Defense experts reinforced that SEA was a rare diagnosis and that Dr. Hospitalist appropriately performed a comprehensive admission H+P with a review of all prior ED visits and radiographic studies, and further examined BF daily and discussed BF’s case with a neurosurgical specialist who provided reassurance that no serious spinal pathology existed. Dr. Hospitalist testified that BF’s exam was dependent on patient participation and, although at times inconsistent, it suggested gradual improvement in his condition. Dr. Hospitalist also testified that he was not fully aware of the RN and therapist impressions at the time, but he trusted his own evaluations as being most accurate.
Plaintiff experts had a hard time reconciling the two conflicting stories in the chart. Additional chart review revealed that on day 2, Dr. Hospitalist inexplicably ordered a CRP and ESR that were both elevated (14.5 mg/dL and 80 mm/hr, respectively) but were never mentioned in the progress notes – nor was the rationale for ordering the studies or an impression of the results. Dr. Hospitalist testified he had no memory of ordering the studies. Moreover, the discharge summary authored by Dr. Hospitalist prior to BF transfer was contradictory to his own progress note documentation:
Hospitalist note, day 2: "There is less pain, actually no pain. The numbness or lack of sensation is improved. The ability to move his left leg is also improved; however, it is still difficult to move it and not because of pain."
Discharge summary: "There were no unifying localizing findings to suggest spinal cord compromise, and much of his symptoms may be related to pain. ... there has been no real progress made in terms of controlling his pain."
Taking all the evidence in aggregate, the plaintiff experts were critical that Dr. Hospitalist seemed unaware of the full range of patient symptoms, the laboratory evidence for an inflammatory process, the reliance on a specialist who never examined the patient, and the inadvertent or intentional chart contradictions.
Conclusion
Charting is one of the four "Cs" in reducing medicolegal risk (charting, competence, compassion, and communication). In this case, the charting by Dr. Hospitalist appeared appropriate on the surface, but inadvertently or intentionally hid the entire clinical picture. The difference in documentation between hospitalist and the RN/therapy notes in this case seems hard to explain, but various health care providers may reasonably see and chart diverse findings and impressions. However, the conflicting documentation between several of Dr. Hospitalist’s own notes severely damaged his credibility.
This case was settled for an undisclosed amount in favor of the plaintiff.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read earlier columns online at ehospitalistnews.com/Lessons.
