Listen to your HEART (score): Documentation and Litigation with Dr. Michael Weinstock

OVERVIEW

Doctors spend up to 2 hours on documentation for every 1 hour with patients, yet we have limited to no training on charting. With their documentation, emergency physicians must make medical decisions while weighing the chance of malpractice claims and the risk for clinical deterioration after discharge. How can we use evidence-based decision tools such as the HEART score to aid our decisions? How do we tell an accurate story with our documentation that minimizes legal risks? Dr. Michael Weinstock breaks it down with tips for your daily practice.

Discussion Questions 

Is there a way to anticipate which patient presentations are prone to rapid deterioration or an inaccurate diagnosis and which patients will then subsequently initiate a lawsuit? What bad habits do we all have when it comes to documentation in general? What recurring themes arise in chest pain litigation? Does the HEART score help or hurt our clinical practice? 

TAKE-HOME POINTS

• Most emergency physicians (75%) will be sued during their career, but most lawsuits (68%) will be dropped, dismissed, or withdrawn. Only a small percentage (7%) will go to trial, though the verdict is usually ((85-90%) for the defense. 
• The most common reason for legal action is a failure to diagnose, but studies show a good bedside manner and appropriate documentation may help avoid a lawsuit. 
• Despite limited training on documentation, we spend an average 2 hours charting for every 1 hour with patients--to the tune of 4,000 mouse clicks per shift!

• Tips for documenting:
• Address every complaint in the HPI
• Be specific in the exam with target “rule-out” 
• Not only pertinent positives, but pertinent negatives
• Ex: erythema, no crepitus or necrosis
• Ex: Child is A&O, running down the hall 
• We all love an EMR Macro, but make sure you add to it! 
• Repeat exams/assessments 
• For your MDM, it’s okay to use plain English to make an argument for why you think “A” is occurring, and “B/C/D” is less likely. 
• Upon discharge, ensure that the patient understands whether there is “diagnostic uncertainty” and that discharge instructions are 1) action-oriented and 2) time-specific.
• One of the most common presentations in the ED, chest pain, represents 8–10 million visits per year, with acute myocardial infarctions being the diagnosis with the highest ratio of paid-to-closed claims. 
• Risk stratification in chest pain patients may be aided by the introduction of high-sensitivity troponin and evidence-based decision tools such as the HEART score; however, it’s important to see these scoring systems as consideration tools, not diagnostic tools. 
• ACEP guidelines allow for a 1-2% acceptable miss rate and studies show most patients with low to moderate HEART scores can safely be discharged home with appropriate understanding and 1-2 week follow-up. 

Resources

• Derse AR. Malpractice Outcome Could Hinge on What ED Nurses Documented. ED Legal Letter (Relias Media). 2017;28(3). 
• Garmel G. 20 Tips for Career Success and Longevity in Emergency Medicine. ALiEM. Oct 13, 2021. 
• Burg MD. A piece of my mind. Gomer. JAMA. 2004;292(16):1935-1936.
• Groszkruger D. Patient ‘Bounced Back’ to Your ED? It’s an Opportunity to Stop Bad Outcome, Lawsuit. ED Legal Letter (Relias Media). 2015;26(9).
• Orman R, Backus B. Origin of the HEART Score. EM:RAP. 2018. Accessed 9 March 2025.
• Rusnak RA, Stair TO, Hansen K, Fastow JS. Litigation against the Emergency Physician: Common Features in Cases of Missed Myocardial Infarction. Ann Emerg Med. 1989;18(10):1029–1034. 
• Swaminathan A. HEAR Score. EM:RAP. 2025.
• The Center for Medical Education. Chest Pain Bounce Backs | 2021 ACOEP Scientific Assembly. YouTube, 17 Feb. 2022. Accessed 9 Mar. 2025.
• Bailey RA. The Litigators Lions Pit: The Top 10 Medical Malpractice Issues Every Resident Should Know. Emergency Medicine Residents’ Association. 
• Guidewire Coaching. The Out-On-Time Course. Accessed 9 Mar. 2025.
• Weingart S. EMCrit 373 - Mike Weinstock with Another Critical Care Bounceback: Asymptomatic Hypertension. EMCrit Project. 18 April 2024. Accessed 9 March 2025.
• Weinstock M. Legally Defensible Charting | Can the Act of Documentation Actually Make a Patient Safer? Michael Weinstock Walks Us through a HA Case That Ultimately Went to Trial for Malpractice,... Essentials of Emergency Medicine. Facebook.com, 2022. Accessed 9 Mar. 2025.
• Weinstock MB, Weingart S, Orth F, VanFossen D, Kaide C, Anderson J, Newman DH. Risk for Clinically Relevant Adverse Cardiac Events in Patients with Chest Pain at Hospital Admission. JAMA Intern Med. 2015;175(7):1207-1212. 
• Wong K, Parikh PD, Miller KC, Zonfrillo MR. Emergency Department and Urgent Care Medical Malpractice Claims 2001–15. West J Emerg Med. 2021;22(2):333-338.

For even more information, check out the new edition of Bouncebacks!, which has actual deposition and trial testimony, real cases, and tons of documentation tips! 

Special thanks to Dr. Matt DeLaney for his help with this episode.