Page 30 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

patient why he/she should have those screenings and

why he/she chose not to. As discussed earlier, obtain a
signature on an informed refusal form if possible.

Following is a case where inadequate documentation hindered

defensibility.

C A S E S T U DY

Following an abnormal stress test, a 50-year-old male

patient underwent a PTCA with stent placement in the

LAD. Following the stent placement, the patient developed
an ischemic right-lower extremity necessitating a return
to the cath lab where the cardiologist reestablished

blood flow to the right leg. The patient was discharged

the following day. Five days later, the patient was seen
by his primary care physician who noted that the
patient complained of pain in both groins and that his

testicles were black and sore. His clinical impression was

ecchymosis on thighs and legs and he prescribed Lortab.
Four days later, the patient was admitted to a hospital
with chest pain and taken to the cath lab where he was

diagnosed with acute stent thrombosis and bleeding. The

patient arrested and could not be resuscitated. Both the
cardiologist and primary care physician were sued.

In a deposition, the primary care physician recalled the

office visit and described the patient as being in a hurry,
wanting pain medication, and refusing additional

diagnostic medical testing. This was not documented.
Also, the PCP’s documentation failed to include any

physical findings – this suggested sloppy care as well.

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