Learn how written discharge instructions can protect your practice

discharge instructions

Accurate, complete and defensive documentation is essential in all areas of practice, and wound care nursing is no exception.

wound care

By Nancy J. Brent, MS, JD, RN

One component of documentation that is of utmost importance is written discharge instructions. In the following case, this was one of the central issues the federal court had to evaluate — Shelton v. United States, 804 F. Supp. 1147.

The patient sought treatment at a VA hospital after he was bitten on the tip of the middle finger of his right hand during an altercation with a female after they left a bar.

The wound was painful and bleeding.  He called 911, stating he had been shot. He would not allow the paramedics to examine his finger.

The ED admitting nurse noted on the admission form he had suffered “trauma” to his right middle finger. He was then seen by an ED physician, whom he told he was bitten and that he had been shot.

The ED physician assessed the wound, irrigated it and determined there was no nerve damage.  She found no puncture or teeth marks nor bone visibly protruding through the skin.

An X-ray was taken, showing no “open fracture,” but there was a fracture at the base of the outer bone of the finger.

Because of the conflicting story of the patient as to the origin of the wound, the physician decided the wound was a “clean” gunshot wound and did not require antibiotics. She orally instructed the patient how to care for the wound after discharge.

Written discharge instructions are documented and signed

A second ER nurse then cleansed and dressed the finger, which included the topical ointment Neosporin. The nurse did not recall the patient saying anything about a human bite as the origin of the wound.

While providing the above treatment for the finger, the nurse reviewed some written instructions with the patient. She reiterated:

  • Icing the finger for the first 24 hours.
  • Keeping it dry.
  • Returning to the ED if increased pain, swelling, discoloration or foul-smelling discharge occurred.

She also told him to return to the ED in about two weeks for a re-examination of the finger.

The patient signed the written discharge instructions and was given a copy to taken home.

Upon arriving home, he went to bed but was unable to sleep because of the pain. The patient took Anacin for the pain, but it did little to reduce it. Several days later, he took the bandage off and saw that his finger was grossly discolored.

The patient returned to the hospital and was seen by a different ED physician. The physician admitted the patient to the hospital and culture results revealed a massive streptococcus infection and an X-ray showed the fracture.

Because of the widespread infection, an amputation of the middle and distal phalanx was done. Physical therapy was ordered and the documentation in the record indicated his prognosis was good, with “some concern about his wrist ROM.”

Patient files negligence suit

The patient filed suit against the hospital under the Federal Torts Claim Act alleging:

  • He was negligently diagnosed and treated for a human bite wound on the middle finger of his right hand.
  • The initial ED physician failed to properly diagnose and treat his finger for a human bite.
  • The ED staff failed to properly instruct him about his wound care when discharged.
  • As a result of their alleged negligence, he developed gangrene and a portion of his finger had to be removed.

The case was tried by the court without a jury.

Insofar as the discharge instructions allegation that involved the nurse, the evidence clearly indicated he had received instructions from both the ED physician (oral) and the ED nurse (oral and written).

The patient also was told to be on the lookout for certain signs of infection.

“Common sense would necessitate some type of inspection of the wound,” the court opined, so the patient could assess the presence of swelling, discoloration or a discharge.

Moreover, the court continued, there was no evidence the patient was unable or incompetent to understand the instructions given to him.

The court also noted that the patient decided not to continue in therapy for his hand and provided no objective evaluation of his employment potential.

The patient’s credible evidence of pain and suffering and his embarrassment because of the disfigurement of his right hand supported a court finding of damages of $20,000.

However, because of his lack of cooperation with treatment and therapy, he was found to be 50% negligent under the applicable “pure comparative negligence law” in his state. Thus, his damages were reduced to $10,000, which you can read more about in “Comparative and Contributory Negligence in Medical Malpractice.”

How documentation can protect your practice

Discharge instructions can create potential legal liability for you as a wound care clinician.

Reduce that risk by taking these steps:

  1. Develop and use current written discharge instructions that the patient signs and takes a copy with him or her.
  2. Assess a patient’s ability to understand discharge instructions by asking the patient to repeat the instructions and/or demonstrate what was taught.
  3. Document that the instructions were given, your assessment of the patient’s understanding and place the second, signed copy of the instructions in the patient’s record.
  4. Follow any facility policy that requires a follow-up call to the patient to assess his or her progress at home with the instructions given. Document any follow-up in the patient’s record, as well.
  5. If the patient’s language is not English, follow facility policy for using an interpreter for patient instructions.

Take one of our wound care courses or certification refreshers to keep your knowledge up to date.

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Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

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