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Over the past several months, my team and I have been asked to review multiple cases involving pressure injuries. We analyze events surrounding pressure injuries occurring in both long-term care and hospital settings and help attorneys determine whether the injuries were avoidable or unavoidable.  For our hospital cases, we frequently refer to a landmark, 2019

83-year-old Lillian presents to urgent care with a cough and cold symptoms. After a thorough workup, she is diagnosed with an upper respiratory infection. Lillian is given a prescription for a 10-day course of penicillin and advised to follow up with her primary physician within the next week. Lillian is stable for discharge. Good to

Which sounds better? · “The patient has a substance use disorder” or “The patient is an IV drug abuser”· “The patient is not tolerating treatment” or “The patient refused treatment”· “Patient with complex health issues” or “Frequent flier”· “Difficulty taking meds due to…” or “Noncompliant”· “Patient has been incarcerated” or “inmate, felon, convict” I think we would

We recently reviewed a case where the patient was portrayed negatively in documentation. There were multiple notes that described the patient as “manipulative”, “drug-seeking”, and “non-compliant”. However, while reviewing the patient’s medical record objectively, we were unable to find any real evidence to support these descriptors. Even if there was, is it helpful to use

“Sticks and stones may break my bones, but words will never harm me.” We all know from experience that the old idiom isn’t true. But what about when it comes to language used in patients’ medical records? Do we need to be extra cautious about the terminology and patient descriptors being used? Can language impact

2-year-old Luna fell off her bunk bed and thankfully landed on her feet. In fact, it was a great landing. She stuck it perfectly. Luna only cried briefly, but now she will not bear any weight. She is crawling around and refuses to walk.  An exam reveals that there is no tenderness to palpation or

How do you rip off the lateral process of your talus?  This post is part III in our “missed fractures” series. Welcome back!  To use non-medical terms, the talar process is a wedge-shaped prominence on the talar bone, which makes up part of the ankle joint. This is the area of concern with 15-year-old Luke,

Take a look at the x-ray above. What stands out to you? Yes, the arrows help. There are teeny tiny fractures at the ends of the bones. These fractures are called metaphyseal fractures – breaks on the metaphysis, which is the growing plate at each end of a long bone. Let’s pretend that these are 6-year-old Bobby’s

6-year-old Evan fell from monkey bars at the park. He is seen in urgent care with complaints of left elbow pain. He doesn’t want to move his arm. There is some swelling around his left elbow and it is very tender to palpation. His left arm is neurovascularly intact and there are no other obvious