1. 1. Situation: A 38 yearmale comesinfor an evaluationof chronicarthralgia. Outside of alonghistory
of arthralgiahe seemshealthy. Hisfamilyhistoryislistedasfatherwithcoloncancerand motherwith
diabetes. Thisisinxxxxx andhe seesanIMDoctor wholeavesapaperrecord forthe visit. IMDoctor
ordersx-raysandlabs to lookfora rheumaticprocess. Inaddition,althoughthe doctor doesnotchart
havingdone so,the doctor ordersa PSA and fastinglipids. The x-raysare negative exceptforarthritic
changesinthe jointsandthe labsare all negative exceptforthe PSA whichis4.79. Whenyou call up his
labin the electronicmedical record itcomesupwitha reference range of 0.0 to 5.0, so at firstglance
4.79 is withinnormal limits. Butthere isalsoan indicatorthatmore informationisavailable inthe
background and whenyouaccessthat informationissaysthatfor a 38 year oldthe reference range is
0.0 to 2.0. I have an electronicrecordwhichshows the exactdate andtime thatIM doctor markedthis
labas “reviewed”. Ihave anotherelectronic recordwhichshowsthe exactdate andtime of the next
appointmentwiththe patient,whichwas2days afterreviewing the lab,andshowsthatthe patientkept
the appointment,butthere isnorecordwhatsoeverof this orany subsequent visitwiththe IMDoc in
the chart. Outside of the electronicappointmentrecordthere isnootherindicationthisvisitever
happened. Thispredateselectroniccharting sothe recordsare all paper.
2. A yearlaterthe patientisseenbya PA foran “annual physical”. Familyhistoryislistedas“Father
coloncancer, Motherlupus”. Thisagain ispapercharting andthere isno electronicrecord. PA makes
no mentionof previousPSA resultbutordersamedand orderslabs,to include PSA. Noprostate exam
ischarted. Patientpicksupnewmedbutdoesnot complete labs. Labssitinthe cue x 1 year before the
orderis dumped. DoesNOTchart any indicationthatpatientunderstood the planof care.
3. 4 yearsafterinitial visitwithIMdoctor the patientisseenbya FNPfor an “annual physical”. Family
historyislistedasfathercoloncancer,motherdiabetes,sisterlupus. Thisisanelectronicencounterand
the FNPcopiesthe PSA of 4.79 from4 yearsearlierintothe note. The FNP makesno othermentionof
the PSA or anypatienteducationprovided. Noprostate examischarted. The FNPstates: “start Mobic.
Get colonoscopy. Getlabs done. Come backfasting.” The FNP doesnot chart any indicationthatthe
patientunderstoodthe planof care. The patientgetsthe colonoscopyandstartsthe new med,but
nevergotthe labs done,whichagainsitinthe cue x 1 year before the orderisdumped.
4. 5 yearsaftervisitwithIMdoctorand 1 yearaftervisitwithFNPthe patient isseenagainforhippain
by a differentFNPwhoordersxrays. The filmscome backdescribingbroadlesionssuspiciousfor
metastasis. The FNPstartsorderingeverything,includingaPSA whichcomesback at 2721. In spite of
effortstothe contrary, 6 monthslaterhe isdead,at age 44. On hisintake formtothe regional cancer
centerhe listsfamilyhistoryas“Father,prostate cancer”.
5. Hiswidowisplacinga claimfor $13.5 million. He isdeposedacouple of monthsbefore he diesand
inhis depositionhe statesthat“Idid everylabtheyevertoldme todo.” He states “I was nevertoldI
had an abnormal PSA testand nobodyeverdidadigital rectal examonme.”
6. So,whoare you goingto believe? Boththe PA and the FNPphysicallyordered the labs. The proof is
inthe electronicmedical record. The FNPspecificallycharts“Getlabs done. Come backfasting.”
Neitherproviderchartsthatthe patientunderstoodthe instructionsandagreedtocomply. The patient
states“I dideverylabtheyevertoldme to do.” Who ismore credible?

2. a. On the day of the encounter in3. above,the dayof the visitwiththe firstFNP, the medical
technicianopensthe encounterat1458 hours. The FNPsignsthe encounterat1528 hours,
exactly30 minuteslater. The FNP lists“40 minutesface toface floortime.” Whois more
credible?
b. 107 dayslaterthe FNPamendsthe encounterat1317 hoursand adds the diagnosis“Blood
pressure isolatedelevated. Randomlycheckbloodpressure andfollow upif itremains
above parametersgiven.” The FNP signsthe encounter,closingitagain,alsoat1317, so the
entire transactiontakeslessthan1 minute. The FNP neversaw the patientpriortothe
initial encounterandthere isnorecord of any contact withthe patientafterthe initial
encounter. The FNP isstatingthat 107 days laterthat she remembersthisspecificpatient
well enoughtorememberthatshe had givenhimthese instructions? Whoismore credible?
c. The patientwastoldto getthe labsdone and start a new medby one provider,andtoget
the labsdone,start a newmed,and get a colonoscopybyanotherprovider. Inbothcases
he understoodwell enoughtostartthe new medandto get the colonoscopy,butnotwell
enoughtoget the labsdone? Who ismore credible?
d. The patientretiredand on25% disabilityfordamage tohislungsfroma single occupational
exposure in aclosedroomto noxioussmoke. He wasa 2 pack a day smokersince he was15
yearsoldand workedforyearsas a concrete worker,aprofessionwhichcreatesasignificant
exposure todustandfumes. Inspite of hisdisability,smoking,andprofession,he never
receivedasingle prescriptionforanybronchodilator,inhaledsteroid,orevenanantibiotic.
He neverhada respiratorycomplaintandwasnevertreatedforanylungproblems. How
real was hisdisability? Whoare yougoingto believe?
Summary.
1. Alwaysreviewyourplanof care withthe patientone lasttime.
2. Checkthe little box “Discussed:Diagnosis,Medication,Treatment,Alternatives,PotentialSide Effects
withthe patientwhoindicated understanding”.
3. It isprobablya goodideato document: “Patientverbalizedanunderstandingof the planof care”.
4. Accurate familyhistoryISimportant. Whatelse ina totallyasymptomaticpatientmighthave leda
providertochecka PSA priorto age 40?
5. Purpose of educationistomotivate patienttofollow the planof care. Don’tbe afraidto use the “c”
wordto motivate them,if thatison the listof possible explanationsforthe abnormal resultyouwant
themto f/uon. “The slightly elevatedPSA couldmeanyouhave prostate cancer. Youcouldhave a
heartattack or stroke because yourbloodpressure istoohigh.”
6. Don’tleave anydoubtsas to yourintegritybyobviousover-billingorpencil-whippeddiagnoses/plan
added107 days later.