I have received a couple of patient complaints alleging that one of our doctors didn’t adequately examine them (the patient). When I reviewed the chart, the doc appears to have dotted all the I’s and crossed all the T’s. I spoke with the doc and he said he clearly remembered the patients and then asked, “How could I have made their diagnoses without examining them?” What are your thoughts?

I’ve seen this a few times over the years and after reviewing the details like you did, I usually thought the doctor’s exam and documentation was appropriate (i.e. the patient complained of abdominal pain and the abdominal, GU, and rectal exams were documented). After discussion and confirmation with the doctor involved, if this is the case, I’ll call the patient back to get their thoughts on what part of the exam was “missing” or inappropriate, and let them know my findings and how a focused physical exam is completed in the ED.

However, I think your question raises a couple of good follow-up thoughts. The first is how we talk to patients during the exam. You can ask patients to open their mouths, but if you comment that they look well hydrated and their throat is normal, they get a better sense of what you’re doing. I usually tell patients after I listen to their heart and lungs what I hear and what their lungs sound like (normal, abnormal, too much smoking, etc…). With the abdomen, you can communicate about normal organ size or bowel sounds. This discussion lets patients know what you’re considering and why you’re doing what you’re doing. Sometimes we can rush through an exam and the patient doesn’t even realize that we listened to their heart and lungs, examined for JVD and leg edema, and palpated their organs. Throw in a visual exam of their eyes, nose and mouth, and a neuro exam based on them walking into the room and talking to you, and we have essentially met the needs to bill for a level 5 exam.

On another note, I don’t think you can ever underestimate the value of touch when it comes to the exam. Whether the patients need it or not, most expect to be touched in some manner by their physician. Yes, you can look in someone’s throat and see an exudative discharge and know your plan and even be writing the discharge instructions in your head. But with another minute, you can also examine their lymph nodes and listen to them breath and the patient will feel that the doctor was very thorough and their bill was more appropriate.

When reviewing a complaint like the one mentioned in your letter, I usually find that the documentation matches the chief complaint; but that doesn’t confirm that the exam actually took place. Take, for instance, the asthma patient who complains that the doctor never listened to their lungs. Hard to believe, yes. But a review must be conducted, so I go back and review the record, particularly if serial exams or ED course is documented. I also would, again, talk to the provider. A peak flow, post walk heart rate and pulse ox, and speech and respiratory patterns can give a provider a pretty good final assessment, but if the provider doesn’t routinely listen to lung sounds at this point, they might need to be educated on the need for patients to be touched and other patient expectations.
A trap that many people could fall into occurs in departments that use dictation or EMR macros for documentation. Sometimes, a false claim is as simple as forgetting to remove certain elements of the standard exam that are automatically included. If an ankle sprain has documentation of tympanic membranes, either your doctor is exceptionally thorough and probably slow and inefficient, or they forgot to remove the macros off the chart. If this is the case, the charting system needs to be fixed.  False documentation can have significant consequences as the Office of the Inspector General (OIG) can implement the False Claims Act for fraudulent document submission and this can carry significant financial damages and criminal prosecution.  It’s worth making sure your computer system and your staff are up to the appropriate task.

With the physician in question, a simple strategy can be followed: investigate, look for trends, and educate. If no trend exists, the documentation fits the chief complaint and the physician verifies their documentation, keeping a watchful eye is probably all that is necessary. If similar complaints come up, further investigation is certainly needed. This might be the time to take a lesson from other service industries and employ a “secret shopper.” This person would come to the ED with a constructed chief complaint, and also with the knowledge of your hospital risk manager and billing group, to be evaluated by the physician in question. Then a comparison of the exam to the documentation can be made. While I can’t say that I’ve ever had to employ this concept, I do recognize it as a possible tool for get better insight into a potentially troubling situation.

Ultimately, the provider may need some education and you will need to close the loop with the patient. Making sure the patient is satisfied will likely save everyone headaches down the road.

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