Claims Case Study: Failure to Follow Appropriate EMR Processes

A 48-year-old diabetic patient presented to the emergency department (ED) with complaints of worsening severe back pain. She had recently undergone an eight-week course of vancomycin for suspected thoracic discitis, and lab values were “worrisome” for recurrent discitis. The decision was made to admit the patient for pain control and additional evaluation, including an MRI of her thoracic spine.

The patient was seen by specialty consultants and multiple hospitalists during her 12-day hospital stay, but her care was primarily managed by one hospitalist for eight consecutive days. This hospitalist consistently documented: “patient feeling better and no motor or sensory deficits.” Later review of the electronic medical record (EMR) via audit trail revealed that the hospitalist used the “copy/paste” function for the assessment from the prior day to the subsequent day with no review or revision.

The nursing notes during this time contradict the hospitalist’s. There are multiple entries regarding the patient’s worsening neurologic status, noting that she had continuing complaints of numbness and tingling in her legs. Her lower extremity strength, which was already limited by her peripheral neuropathy, worsened to the point that she could not stand to transfer to the bedside commode or chair, activities that she could easily do prior to this hospitalization. Even though the hospitalist was aware of her prior history of thoracic discitis, he only ordered a lumbar MRI, and attributed her pain and loss of lower extremity strength and movement to “deconditioning.”

The patient’s husband requested an inpatient neurology consult, but the hospitalist denied the order, stating that the patient could see a neurologist after discharge from the hospital. At this time, the patient’s husband complained to the hospital’s risk management department.

Unable to move or feel her legs, the patient was ultimately discharged to a rehabilitation hospital/skilled nursing facility. Shortly after admission, the attending physician ordered a thoracic MRI that was significant for T8-T9 discitis with paravertebral abscess. Surgical decompression was performed, but the patient remained a paraplegic until her death 18 months later due to a stroke.

What Went Wrong?

An examination of the audit trail for the EMR easily discerned that the hospitalist continuously repeated the “copy/paste” functions for the patient’s assessment. This fact, along with the stark differences between the nursing notes and assessments compared to those of the hospitalist, made it difficult to defend this insured’s care. It provided the plaintiff with a compelling argument that the hospitalist was not taking the necessary time to fully evaluate and record changes to the patient’s condition as they were happening, which may have affected care decisions throughout her hospital stay. Furthermore, the hospitalist failed to review notes from additional care staff and ED records or communicate with the nursing staff, leading to a failure to recognize the differences between their observations of the patient’s condition.

Key Takeaways

• Practice leaders should require that all staff members complete adequate training with EMR systems. Note that there are sometimes differences across EMR software and procedures within the same health system, such as different templates and processes for outpatient and inpatient care.
• Attending physicians and consultants should review all notes prior to their last documented interaction with the patient.
• Using the copy/paste function is a reality of EMR systems, but providers should use it judiciously. EMR audit trail requests (by both plaintiff and defense attorneys) have now become standard during the investigation and work-up of a medical malpractice lawsuit, and overuse of this function may indicate a lack of attention to detail.

The opinions expressed herein are not intended as legal advice. We have found that the use of such information reduces the risk of medical malpractice claims, but we cannot guarantee that following this advice will prevent a claim against you or your practice.