Timing of Rectal Bleeding Complaint Disputed

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

From 1994 to 2005, a Florida woman, age 40, was a patient of the defendant primary care physician. In 2000, she began to experience rectal bleeding, of which she claimed to have advised her doctor over the years. The physician denied that the patient ever complained of rectal bleeding before June 2005, and whether she had mentioned the problem while in his care was hotly contested.

A rectal exam was performed in October 2000, at which time the patient was noted to have hemorrhoids. However, hematology and stool hematests were negative. The physician maintained that the hemorrhoids remained stable.

The physician did not refer the woman to a gastroenterologist for evaluation until June 2005, when a complaint of rectal bleeding was first documented. In July 2005, the woman was diagnosed with rectal cancer and required removal of the right lobe of the liver due to its spread.

Outcome
According to published reports, a $9,728,835.15 verdict was returned. Posttrial motions were pending.

Comment
After a poor outcome, patients may have a skewed view of how, when, and to whom they have made complaints. Motivated by fear, or a desire to maintain a fully functional status, patients may hide symptoms from their clinician, only to later recollect that such symptoms were communicated, when in fact they were not.  

Legal cases involving an “unspoken complaint” often turn on the perceived credibility of the witnesses and little else. Two strategies may prove useful to minimize the risk of the uncommunicated complaint.

First, it is helpful for a practice to have multiple layers to record and capture patient complaints. Having the patient record the reason for her visit, in writing, in her own words, can improve documentation and care. On occasion, a patient’s written self-complaint can be useful to catch a symptom that may slip by during history taking. Further, medical assistants, nursing staff, and other professionals should also record patient complaints directly—habitually using quotation marks to capture the patient’s actual language where possible and appropriate. Lastly, the clinician should make a practice of first seeking the history independently, only using the patient self-report and nursing assessment to make sure all symptoms and signs have been addressed. This three-tiered system will provide a solid record for what was communicated and make clear the symptoms that were described.

But what about those complaints not communicated? A patient’s record may be “closed” through a technique known as “exhaustion.” Here, clinicians can borrow a page from attorneys: During deposition, attorneys are trained to “exhaust” all possible avenues of evidence for each possible area of questioning. The questioner will conclude by confirming for the record that the deponent has “exhausted” his memory and cannot provide any additional detail.

Clinicians, after receiving the history of present illness (HPI) and recording all pertinent positives and negatives, can “exhaust” the history by asking: “Apart from what you have already told me, do you have any other symptoms? Is anything else bothering you at all?” While clinicians often ask such a question, the response is frequently not recorded. The patient’s negative answer may be documented with language akin to: “Patient denies any additional symptoms or complaints.” Ending the history portion of the clinical note this way closes the record to additional complaints. A clinician is then well positioned to testify that it is his practice to end history taking in a manner calculated to “catch everything” and has documentation to support that claim.

Plaintiff’s counsel, reviewing records and contemplating suit, will find layer upon layer of harmonious documentation, from several professionals. This is far more defensible than a simple set of vital signs with a single brief HPI that, years later, may be cryptic at best. —DML

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

From 1994 to 2005, a Florida woman, age 40, was a patient of the defendant primary care physician. In 2000, she began to experience rectal bleeding, of which she claimed to have advised her doctor over the years. The physician denied that the patient ever complained of rectal bleeding before June 2005, and whether she had mentioned the problem while in his care was hotly contested.

A rectal exam was performed in October 2000, at which time the patient was noted to have hemorrhoids. However, hematology and stool hematests were negative. The physician maintained that the hemorrhoids remained stable.

The physician did not refer the woman to a gastroenterologist for evaluation until June 2005, when a complaint of rectal bleeding was first documented. In July 2005, the woman was diagnosed with rectal cancer and required removal of the right lobe of the liver due to its spread.

Outcome
According to published reports, a $9,728,835.15 verdict was returned. Posttrial motions were pending.

Comment
After a poor outcome, patients may have a skewed view of how, when, and to whom they have made complaints. Motivated by fear, or a desire to maintain a fully functional status, patients may hide symptoms from their clinician, only to later recollect that such symptoms were communicated, when in fact they were not.  

Legal cases involving an “unspoken complaint” often turn on the perceived credibility of the witnesses and little else. Two strategies may prove useful to minimize the risk of the uncommunicated complaint.

First, it is helpful for a practice to have multiple layers to record and capture patient complaints. Having the patient record the reason for her visit, in writing, in her own words, can improve documentation and care. On occasion, a patient’s written self-complaint can be useful to catch a symptom that may slip by during history taking. Further, medical assistants, nursing staff, and other professionals should also record patient complaints directly—habitually using quotation marks to capture the patient’s actual language where possible and appropriate. Lastly, the clinician should make a practice of first seeking the history independently, only using the patient self-report and nursing assessment to make sure all symptoms and signs have been addressed. This three-tiered system will provide a solid record for what was communicated and make clear the symptoms that were described.

But what about those complaints not communicated? A patient’s record may be “closed” through a technique known as “exhaustion.” Here, clinicians can borrow a page from attorneys: During deposition, attorneys are trained to “exhaust” all possible avenues of evidence for each possible area of questioning. The questioner will conclude by confirming for the record that the deponent has “exhausted” his memory and cannot provide any additional detail.

Clinicians, after receiving the history of present illness (HPI) and recording all pertinent positives and negatives, can “exhaust” the history by asking: “Apart from what you have already told me, do you have any other symptoms? Is anything else bothering you at all?” While clinicians often ask such a question, the response is frequently not recorded. The patient’s negative answer may be documented with language akin to: “Patient denies any additional symptoms or complaints.” Ending the history portion of the clinical note this way closes the record to additional complaints. A clinician is then well positioned to testify that it is his practice to end history taking in a manner calculated to “catch everything” and has documentation to support that claim.

Plaintiff’s counsel, reviewing records and contemplating suit, will find layer upon layer of harmonious documentation, from several professionals. This is far more defensible than a simple set of vital signs with a single brief HPI that, years later, may be cryptic at best. —DML

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

From 1994 to 2005, a Florida woman, age 40, was a patient of the defendant primary care physician. In 2000, she began to experience rectal bleeding, of which she claimed to have advised her doctor over the years. The physician denied that the patient ever complained of rectal bleeding before June 2005, and whether she had mentioned the problem while in his care was hotly contested.

A rectal exam was performed in October 2000, at which time the patient was noted to have hemorrhoids. However, hematology and stool hematests were negative. The physician maintained that the hemorrhoids remained stable.

The physician did not refer the woman to a gastroenterologist for evaluation until June 2005, when a complaint of rectal bleeding was first documented. In July 2005, the woman was diagnosed with rectal cancer and required removal of the right lobe of the liver due to its spread.

Outcome
According to published reports, a $9,728,835.15 verdict was returned. Posttrial motions were pending.

Comment
After a poor outcome, patients may have a skewed view of how, when, and to whom they have made complaints. Motivated by fear, or a desire to maintain a fully functional status, patients may hide symptoms from their clinician, only to later recollect that such symptoms were communicated, when in fact they were not.  

Legal cases involving an “unspoken complaint” often turn on the perceived credibility of the witnesses and little else. Two strategies may prove useful to minimize the risk of the uncommunicated complaint.

First, it is helpful for a practice to have multiple layers to record and capture patient complaints. Having the patient record the reason for her visit, in writing, in her own words, can improve documentation and care. On occasion, a patient’s written self-complaint can be useful to catch a symptom that may slip by during history taking. Further, medical assistants, nursing staff, and other professionals should also record patient complaints directly—habitually using quotation marks to capture the patient’s actual language where possible and appropriate. Lastly, the clinician should make a practice of first seeking the history independently, only using the patient self-report and nursing assessment to make sure all symptoms and signs have been addressed. This three-tiered system will provide a solid record for what was communicated and make clear the symptoms that were described.

But what about those complaints not communicated? A patient’s record may be “closed” through a technique known as “exhaustion.” Here, clinicians can borrow a page from attorneys: During deposition, attorneys are trained to “exhaust” all possible avenues of evidence for each possible area of questioning. The questioner will conclude by confirming for the record that the deponent has “exhausted” his memory and cannot provide any additional detail.

Clinicians, after receiving the history of present illness (HPI) and recording all pertinent positives and negatives, can “exhaust” the history by asking: “Apart from what you have already told me, do you have any other symptoms? Is anything else bothering you at all?” While clinicians often ask such a question, the response is frequently not recorded. The patient’s negative answer may be documented with language akin to: “Patient denies any additional symptoms or complaints.” Ending the history portion of the clinical note this way closes the record to additional complaints. A clinician is then well positioned to testify that it is his practice to end history taking in a manner calculated to “catch everything” and has documentation to support that claim.

Plaintiff’s counsel, reviewing records and contemplating suit, will find layer upon layer of harmonious documentation, from several professionals. This is far more defensible than a simple set of vital signs with a single brief HPI that, years later, may be cryptic at best. —DML