The Importance of Documenting Discharge Information

The patient was a 62-year-old man with a history of diabetes, neuropathy, and peripheral vascular disease. He worked in construction and hoped to retire in the next few years. He was the main source of financial support for his family, including a grandchild that he and his wife were raising.

One day at work, a heavy box fell on his foot causing him great pain and bruising. He tried to continue working and allow it to heal on its own, but, after 3 days and no improvement, his wife encouraged him to go to the emergency department of the local hospital.

At the hospital, he was cared for by the emergency department physician. The doctor examined the patient’s foot and noted that it was red, swollen, and badly bruised, but that he had full range of motion of the foot, and there were no skin tears, abrasions, or bleeding. The patient was sent for an x-ray which came back negative for breaks or fractures.

The physician diagnosed the patient with a contusion.

“We are going to put a splint on your foot so that you don’t bend or flex it,” the physician told the patient. “It will heal faster if you don’t move it.”

A posterior splint was placed on his foot. Neither the doctor nor his physician assistant documented any patient evaluation after the splint was placed on his foot.

Upon discharge, the doctor gave the patient verbal instructions, which included that he should remove the splint when showering or if it felt too tight. “You should come back to the emergency department right away if you notice any color changes in your foot, or if the pain gets worse or your foot becomes numb.” The patient nodded, and he assumed he understood the directions. The physician did not provide the patient with written discharge instructions.

The physician recommended to the patient that he follow up with orthopedics in a week, and he noted this in the patient’s record.

The patient thanked him and left, but 2 days later he returned to the emergency department with color changes and complaints of pain in the injured foot. The patient told the nurse that he had not removed the splint since it had originally been placed in the emergency department 2 days earlier. The patient now had gangrenous necrosis of the foot. Despite medical treatment, the patient required partial amputation of the affected foot, making it impossible for him to continue working his physically demanding job.

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