Legal Pearls: The Importance of Documenting Discharge Information

A 62-year-old man with a history of diabetes, neuropathy, and peripheral vascular disease, came to the emergency department (ED) 3 days after a heavy box fell on his foot at work causing him great pain and bruising. At the ED, a physician diagnosed the patient with a contusion.

A posterior splint was placed on the patient's foot. Neither the doctor nor his physician assistant documented any patient evaluation after the splint was placed on the foot, and the doctor did not provide the patient with written discharge instructions.

Two days later, the patient returned to the emergency department with color changes and complaints of pain in the injured foot. Despite medical treatment, the patient required partial amputation of the affected foot.

Was the doctor negligent?

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Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.