The Importance of Thorough Physical Exam Documentation

Although documentation through the years has changed from paper notes to electronic, the basic tenets of documentation have remained the same and are especially important to capture thorough documentation of an assessment. It is important to remember that no matter if the physical assessment is documented electronically or manually, it should still reflect a picture of what the patient looked like upon presentation and what happened during their visit.

“Document, document, document!” This is a common phrase within the healthcare community that is supposed to encourage staff to document more detailed findings after conducting thorough exams. Physicians must thoroughly document all components of their comprehensive physical examinations when assessing a patient. Just as thorough assessments are the key to making a diagnosis and identifying potential threats to a patient’s health, thorough documentation provides the roadmap supporting the diagnosis reducing the likelihood of successful claims or litigation against your office practice or healthcare facility.

However, limited documentation can have negative effects.

The Claim

Consider this case involving a 44-year-old female patient who presented to the emergency department with complaints of posterior neck, shoulder, and upper back pain that had been present for four days. The initial neurological exam was documented as “neurologic: normal speech and moves all extremities.” She was diagnosed with muscle spasms and given Percocet, Toradol, and Valium before being discharged.

The same patient returned to the emergency department 15 hours post-discharge with complaints of numbness over her entire body. The chart was documented under neurologic exam as follows, “alert and oriented x 3, GCS 15, normal mentation, and speech. Moves all extremities x 4 without motor deficit.” She was given a diagnosis of adverse drug reaction. The patient was treated for the drug reaction and once again discharged.

The following day the patient presented again, this time with urinary retention and an inability to walk. An MRI was performed revealing a 7mm posterior projection at C5-6. The patient was stabilized and transferred to a higher level of care for emergency neurosurgical intervention.

At trial, the plaintiff’s attorney focused on the limited documentation supporting the thoroughness of the exams conducted on the first two visits to the emergency department. Unfortunately, the jury agreed with the plaintiff and at trial awarded the patient a total of $14,250,000.00. This award included $250,000.00 for past medical bills, the cap of $500,000.00 for general damages, and $13,500,000.00 for future medical care.

Benefits of Thorough Documentation

Clinical documentation is such an important part of our work as physicians. Good documentation serves several purposes that merit mentioning here:

1. It serves as a method of communication among healthcare providers. It gives the next care provider an understanding of what your assessment findings were when you saw the patient, treatment plans, and the patient’s response to treatment. Documentation aids in the continuity of care across the healthcare continuum for the patient. In the case described above, it is not clear if the same physician saw the patient at each separate visit. However, the documentation for each time was not descriptive enough for the next provider to build upon.
2. Documentation serves as a legal record of care. Good documentation can support clinical judgment just as poor documentation can give the impression of negligence. The limited assessment documentation in the above-referenced claim is a good example of how documentation can paint a negative picture. Reading the assessment information above makes one think that the assessment was not thorough, did not address the chief complaint, and hurried decisions were made resulting in negligence in care.
3. Documentation supports care toward nationally recognized standards of care for performance improvement purposes and quality reporting. Certain chief complaints require specific assessments, diagnostics, and treatments to be done within designated timeframes. Much of this information is used as a basis for reimbursement of the healthcare organization.

In the emergency department, providers encounter many patients with whom they have no past relationship and therefore have no knowledge of the patient’s health history. There must be a balance between doing a comprehensive history, a physical, and a focused assessment to appreciate appropriate differential diagnoses.

The SOAP Note

Using a structured format, such as SOAP: subjective, objective, assessment, and plan, the emergency department notes should focus on documentation of pertinent information to address the patient’s chief complaint.

• S – Subjective Data Section

In the emergency department, this section should focus on the chief complaint and a chronological history of the presenting condition. This section is obtained directly from the patient’s own words. The questions asked in this section should concentrate on factors that the provider feels may be pertinent to the chief complaint. Documentation of medication history and allergies can also be documented here.

• O – Objective Data Section

The objective section is documentation of measurable and observable data collected by the provider. This is the physical assessment data. This portion of the note is vitally important and should contain exactly what exams were performed. The adage “if it isn’t documented, you didn’t do it” applies here – it is important to be concise with documentation. Whether the result of your assessment is positive or negative, if it is pertinent to the chief complaint, the notes should reflect that the assessment was completed and considered in the determination of diagnosis. In the above-referenced claim, objective data is exactly what is lacking in the documentation. The notes do not address the chief complaint only basic and limited neurologic assessment information.

• A – Assessment

The assessment portion of the notes should address the clinical decision-making process. This is where the provider puts together all the information gathered and highlights the decision-making process of possible differential diagnoses and treatment plans to be considered. It is also where the provider can summarize the big picture.

• P – Plan

In the plan section, the provider should detail the treatment plan. In addition, notes should indicate what future diagnostic workups and options for treatment and follow-up should be in the event the patient does not improve.

Although documentation through the years has changed from paper notes to electronic, the basic tenets of documentation have remained the same and are especially important to capture thorough documentation of an assessment. It is important to remember that no matter if the physical assessment is documented electronically or manually, it should still reflect a picture of what the patient looked like upon presentation and what happened during their visit.

Learn More

For more resources view the LHA Trust Funds Emergency Department toolkit.

About the Authors

Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.