FACEM Documentation and Record Keeping 3 — Questions and Answers
Question 1: A patient presents with a minor laceration but later develops compartment syndrome. Your initial documentation contained no neurovascular assessment. What is the medicolegal implication?
- No implication if the injury was not present at initial assessment
- The absence of documented neurovascular assessment suggests it was not performed (Correct answer)
- You are protected because compartment syndrome is rare
- Documentation gaps have no legal relevance in emergency medicine
Correct answer: The absence of documented neurovascular assessment suggests it was not performed
Legally, 'if it wasn't documented, it wasn't done'—absence of neurovascular documentation implies the assessment was not performed, creating significant liability.
Question 2: Which element should be included when documenting informed consent in the ED?
- Only the patient's signature on the consent form
- Nature of the procedure, risks, benefits, alternatives, and patient questions addressed (Correct answer)
- A generic statement that 'risks and benefits were discussed'
- Consent documentation is only required for surgical procedures
Correct answer: Nature of the procedure, risks, benefits, alternatives, and patient questions addressed
Informed consent documentation must capture the specific elements discussed including risks, benefits, alternatives, and any questions the patient raised.
Question 3: When documenting a patient's Glasgow Coma Scale (GCS) in the ED, best practice requires:
- Recording only the total GCS score
- Recording the total score AND the individual component scores (E, V, M) (Correct answer)
- Documenting GCS only on initial assessment
- Recording GCS only if the score is below 15
Correct answer: Recording the total score AND the individual component scores (E, V, M)
Documenting individual GCS components (Eye, Verbal, Motor) provides more clinical detail than the total score alone and allows for accurate trend monitoring.
Question 4: A patient is transferred from ED to the ICU. The transfer documentation should include:
- Only the admission diagnosis and vital signs
- Clinical summary, outstanding investigations, current management, and specific handover concerns (Correct answer)
- Only the medication reconciliation list
- A brief one-line summary to save time during busy periods
Correct answer: Clinical summary, outstanding investigations, current management, and specific handover concerns
Transfer documentation must be comprehensive, covering clinical status, pending results, current interventions, and specific concerns to ensure safe continuity of care.
Question 5: When documenting a difficult or failed intubation, which element is MOST critical to include?
- The total time taken for the procedure
- Laryngoscopy grade, attempts made, devices used, and airway management plan (Correct answer)
- Only the final method that achieved successful intubation
- A note that the anesthesia team was not available
Correct answer: Laryngoscopy grade, attempts made, devices used, and airway management plan
Difficult airway documentation must capture laryngoscopy findings, number of attempts, all devices used, and the ongoing airway plan to protect future providers and the patient.
Question 6: A patient discloses domestic violence during an ED visit. Regarding documentation:
- Document all details in full including perpetrator name, regardless of patient consent
- Document the disclosure, safety assessment, resources offered, and patient's response, with sensitivity to privacy (Correct answer)
- Omit the disclosure entirely to protect the patient's confidentiality
- Only document if mandatory reporting laws require it in your jurisdiction
Correct answer: Document the disclosure, safety assessment, resources offered, and patient's response, with sensitivity to privacy
Domestic violence disclosures require sensitive, accurate documentation of the assessment and response while balancing the patient's safety and privacy preferences.
Question 7: Which of the following is the correct approach when a clinical note contains a factual error?
- Delete the original entry and rewrite it from scratch
- Draw a single line through the error, initial and date it, then add a correction (Correct answer)
- Use correction fluid (white-out) to cover the error neatly
- Leave the error to avoid drawing attention to it
Correct answer: Draw a single line through the error, initial and date it, then add a correction
The correct method is a single strikethrough preserving legibility of the original entry, with initials, date, and a correction—never obliterate original text.
FACEM Documentation and Record Keeping 3
A patient presents with a minor laceration but later develops compartment syndrome.
Your initial documentation contained no neurovascular assessment.
What is the medicolegal implication?