Index Case 7
Ankle Injury
Testing and Treatment
Disposition
Billing
Return ED Visit
Outcome
Plaintiff Claims
Defense Response
Legal Outcome
Case Review
Documentation Review
Given the lack of emergency results on the tests, the physician elected to discharge the patient. Repeat vitals were measured and are shown below. For easy comparison, triage vitals are shown on the left and discharge vitals shown on the right.
The doctor’s medical decision-making is shown here:
Here are the discharge instructions:
Nursing discharge documentation:
Does this seem like a reasonable discharge plan? Are there any other questions you would have wanted to ask the patient? Recall that the patient had been seen at a clinic next door to the ED, and referred to the ED. It would later be discovered that the reason the patient was referred to the ED is because his temperature was 100.2 F, and his blood pressure was 81/38. There was no mention of these vitals in the ED record. It is unclear if the ED staff was aware of these vitals and simply did not document them, or if the staff was not aware.
What do you think the outcome will be? On the next page we will make a quick detour to review the billing aspects of this chart.