Learn how documentation can significantly benefit patients and providers.
A 29-year-old gravida 5, para 4 patient presented for her first prenatal visit at 10 weeks by her last menstrual period (LMP). She had a history of 4 prior vaginal deliveries: 3 were full-term and uncomplicated, and 1 was at 36 weeks in the setting of a stillborn fetus with trisomy 18 and multiple fetal anomalies. Her last pregnancy was notable for gestational hypertension but otherwise her pregnancies and deliveries were uncomplicated.
Her medical history was notable for migraine headaches with aura and varicose veins in the left leg. She had no history of hypertension (aside from the gestational hypertension noted above) and no history of diabetes inside or outside of pregnancy. She denied having a history of blood clots, including no family history. She had used oral contraceptives prior to the current pregnancy without incidence. She was a nonsmoker. Her body mass index was 45 kg/m2.
At her first prenatal visit at 9 weeks and 4 days of gestation, she noted some morning nausea but was able to tolerate food without difficulty. On review of systems, she reported no difficulty sleeping and no shortness of breath. She had no recent travel or long car rides and was able to climb stairs as she had before. However, she did note that her activity level was decreased because of her morning sickness, and she would remain in bed for several hours. She also complained of worsening pain in her legs, noting that although she has had long-standing varicose veins that made it difficult to walk, stand or put pressure on her legs, her symptoms on the left leg worsened significantly the day before. She described having a “shooting pain up and down” her left leg.
On physical examination, the patient was in no acute distress. She was speaking in full sentences and did not have labored breathing. Her vital signs were within normal limits, with a blood pressure of 116/64 mm Hg and a heart rate of 76 beats per minute (bpm). She weighed 273 pounds. Her heart had a regular rate and rhythm, her abdomen was soft and nontender, and her lungs were clear bilaterally. Her pelvic exam was normal, noting an appropriately enlarged uterus. Examination of her extremities noted swelling of both legs, the left greater than the right. No erythema was noted, and no palpable cords could be appreciated.
A bedside transvaginal ultrasound was notable for an intrauterine pregnancy. Crown-rump length measured 9 weeks and 4 days, corroborating the gestational age by her LMP. Fetal heart tones were noted in the 150s, and no maternal adnexal masses were seen.
The patient was given prenatal education packets as well as an order for her prenatal labs, and a formal first trimester ultrasound. Because of to the patient’s symptoms and her leg edema on exam, she was also given an order for an urgent lower extremity ultrasound with Doppler.The provider’s documentation included a differential diagnosis for causes of her symptoms and physical exam findings, including potential next management steps if the Doppler ultrasound of the leg was within normal limits.
The patient had her labs drawn in the laboratory on the first floor of the clinic and then proceeded out of the clinic building. While walking across the parking lot to the hospital to have her lower extremity ultrasound, she started feeling unwell and sat on a bench on the sidewalk. She then sustained a witnessed fall from the bench and 911 was called by bystanders on the street.
On arrival, paramedics noted she was initially unconscious. Her heart rate was 131 bpm and oxygen saturation was 75% on ambient air. Blood pressure was not able to be obtained and the patient was noted to have weak radial pulses but good pulses in the carotids. Intravenous access for fluids was established, an oxygen mask secured, and the patient regained consciousness. Her blood pressure was 166/122 mm Hg and heart rate was 153 bpm. The patient was taken emergently across the street to the hospital emergency department (ED).
In the ED, the patient complained of difficulty breathing and abdominal pain. She was very agitated and unable to follow complete commands. She described feeling dizzy and nauseated before sitting on the sidewalk bench but could not recall falling or the 911 response. She was on supplemental oxygen but was grabbing at the mask because of her agitated state.
Vital signs were notable for a blood pressure of 172/99 mm Hg and a heart rate of 160 bpm. Oxygen saturation was 90% on a nonrebreather face mask. Physical examination revealed labored but symmetric breathing, with clear lungs bilaterally to auscultation. The heart exam revealed a regular rhythm without extra heart sounds. Radial and femoral pulses were both weak. The patient was able to move all extremities. Lower extremities were notable for edema with left greater than right. A bedside ultrasound demonstrated no free fluid in the abdomen and an early intrauterine pregnancy was confirmed. Ultrasound of the lower extremities was planned.
A femoral line was placed, and labs were drawn. Shortly thereafter the patient became unresponsive and was noted to be grinding her teeth and biting her lip. Her pupils became fixed and dilated. Blood pressure at this point was 148/106 mm Hg and heart rate was 54 bpm. She was immediately intubated, and her airway was secured.
Within minutes, she went into pulseless electrical activity (PEA) cardiopulmonary arrest. Cardiopulmonary resuscitation (CPR) was initiated. Differential diagnosis at this point was a pulmonary embolism, intracranial hemorrhage, seizure, toxidrome, or unknown cause. Ultrasound of lower extremity revealed a superficial venous thrombus. The deep venous system could not be fully evaluated. Tissue plasminogen activator (tPA) was given as pulmonary embolism (PE) was presumed more likely than an intracranial bleed. Despite maximal efforts at resuscitation, the patient continued in PEA arrest, and she was pronounced dead after 50 minutes of CPR. On autopsy, a PE of the main right pulmonary artery was found to be the cause of death.
This case was reviewed by a medical expert for the plaintiff. Critical documentation during her prenatal visit noted several risk factors for venous thromboembolism. Her providers considered deep venous thrombosis in their differential diagnosis, ordering an urgent lower extremity ultrasound with Doppler. Her obstetrician documented that her status was stable, such that emergent transfer to the ED was not required. The obstetrician was unaware that the patient had become unresponsive outside of their clinic building.
Documentation and response by the ED physicians, particularly noting the acute change in her status was appropriate. It was noted that thorough documentation occurred shortly after the patient was pronounced dead, which was considered appropriate under the circumstances.
After an extensive review it was determined that, although this was a tragic outcome of an infrequent, but very morbid condition, the documented care met the applicable standard of care. As such, a medical negligence suit was not filed.
The lack of adequate and appropriate documentation is often cited as a root cause for medical malpractice actions. This case demonstrates how appropriate documentation avoided a negligence suit. Documentation included the pertinent historical and clinical information, and there was a complete and thoughtful physical examination with an appropriate differential diagnosis, including the actual diagnosis. Appropriate laboratory and imaging tests were ordered in a timely manner. Response at the ED was appropriate, administered in a timely and competent manner, with appropriate documentation. As such, the reviewer concluded that the providers acted reasonably under the circumstances and within the applicable standard of care. Documentation that is less complete and timely could have resulted in an allegation that the patient’s complaints were not taken seriously or that the acuity of her condition not recognized, with a subsequent delay in care resulting in the patient’s death. The documentation addressed these concerns.
It was noted that the ED providers’ documentation primarily occurred after the patient succumbed. Noting the acuity of the situation and the patient’s in extremis status, documentation shortly after the event was acceptable. Timely documentation is critical in appropriate patient care and in avoidance of subsequent suit when there are adverse outcomes. It is also recommended that physicians and providers debrief with the nursing and support staff after an acute event, assuring consistent documentation by all involved parties.