Index Case 7
Ankle Injury
Testing and Treatment
Disposition
Billing
Return ED Visit
Outcome
Plaintiff Claims
Defense Response
Legal Outcome
Case Review
Documentation Review
The patient continued to feel poorly at home. He called into the ED 2 days later, discussed his symptoms, and was told to take ibuprofen. This phone call was not documented and it is unclear to whom he spoke. 3 days after his discharge, he returned to the ED. The entire record is shown below:
The rest of the note, testing, and MDM are shown below.
The patient was admitted by a hospitalist, and had surgical and infectious disease consults. The next page will show selections from the progress notes and outcome.