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ProAssurance Risk ManagementJune 20244 min read

Communication and Documentation Critical in Defense of Care in Negligence Claim

Communication and Documentation Critical in Defense of Care in Negligence Claim

The spouse of a deceased patient alleges that the patient, who had a history of a seizure disorder, should not have been medically cleared for admission to an alcohol rehabilitation facility without medically supervised detoxification.

Case Details

This case stems from a seemingly straight forward emergency department visit to medically clear a patient for rehab. It highlights the importance of having a clear understanding of the reason a patient is presenting to the emergency department, as well as the importance of conducting a complete history, exam, and physical and thoroughly documenting the patient visit.

A 42 YOM was seen in the emergency department (ED) to receive medical clearance to enter an inpatient alcohol treatment program the next day. The nursing triage note stated “requests medical screening for beginning rehab tomorrow for alcohol.” The patient, accompanied by his wife, was seen by an emergency medicine physician. The patient told the physician that in order to be admitted to a rehab facility, he was required to undergo a medical evaluation to affirm he can go through withdrawals without medical problems. The patient’s wife told the ED staff that that the patient had a pre-existing head injury, and that he had seizures, but the seizures had nothing to do with alcohol. The patient reported some back pain but denied shortness of breath, chest pain, nausea, vomiting, fever, or chills. The physician noted a history of alcohol abuse, seizures, and a CAGE score of 3/4 positive responses. Physical exam in the ED revealed temperature of 98.4 degrees, pulse of 114 bpm, respiratory rate of 16 br/min, blood pressure of 146/100, and pulse oximetry of 97%. The only medication noted in the record was eslicarbazepine acetate for seizure disorders.

The physician noted that the physical exam was negative and gave the patient a note to clear him for a rehab facility, discharged him home in stable condition, and instructed him to follow up with his primary care provider if necessary or to return to the ED sooner if needed. The patient checked into the rehab facility the next day and was found dead in his bed about five hours later. A pathologist found the cause of death was a seizure disorder. The decedent’s blood ethyl alcohol was 0.11.

The patient’s spouse brought suit against the emergency department physician and the rehab facility. She alleged that the physician was negligent for clearing him to go to a non-medically-supervised rehab facility. The physician testified that he was asked to medically clear the patient for the rehab program. There was no testimony or medical record documentation indicating that he was asked to determine whether the patient should only attend a medically supervised rehab facility.

There was a dispute in the case as to how much work up was necessary to medically clear the patient for rehab. The physician noted back pain, but the review of systems was otherwise within normal limits. The physician noted that the patient had a history of seizures and also that the patient was on seizure medication.

Expert Testimony

Experts for the defense felt that the physician had met the standard of care by performing an appropriate examination to clear a patient for rehab. The patient’s blood alcohol level was 0.11. The defense expert on causation opined that it is more probable than not that this patient died from a sudden seizure unrelated to any withdrawal from alcohol.


The unfortunate outcome in this case could have possibly been prevented if the patient had been admitted to a medically supervised rehab facility. Experts for the defense found that the culpable party in this case was primarily the rehab facility, not the physician in the emergency department.

Due to the strength of the testimony of the physician supported by his medical record documentation, the case ended in a verdict for the defense. The rehab facility however, was found to have been negligent.

Risk Reduction Strategies

Establish a Clear Understanding of Patient’s Presenting Needs and the Patient’s HPI

To the extent possible, elicit information from the patient or accompanying friend or family member to have a clear understanding of what the patient needs and expects from the visit. When a patient is presenting with a request for a clearance note or a form to be completed, determine what information needs to be communicated.

Conduct an Appropriate History, Exam, and Physical

In addition to determining the needs of the patient, the patient interview should illicit a detailed patient history. The patient interview, history, and physical should support the work up to be conducted.

Thoroughly Document the Patient ED Visit

Create an accurate record of what occurred during a patient encounter and demonstrate the thought processes, rationale, and medical decision making. When a physician’s care comes into question, lack of documentation can significantly diminish a physician’s ability to support the treatment as meeting the standard of care.

Communication and documentation are crucial for healthcare providers to do their jobs effectively. Documentation during the patient encounter—particularly of information gathered; assessments and plans; and the rationale for decisions—goes a long way toward supporting patient care and defending that care in the event of a claim.


If you have questions on this topic, please contact us at or 844-223-9648.


ProAssurance Risk Management

The ProAssurance Risk Management department is here to help you promote patient safety, minimize risk, and improve defensibility of claims by providing comprehensive assessment and training resources that are relevant and easy to share. If you have a question you would like to discuss with a risk consultant, email or call 844-223-9648.