LEGAL CORNER / THE DIABETIC FOOT

The “Significant Seven” Issues About Medical Charting and Diabetic Patients

Proper documentation is the key to protecting you.

BY LAWRENCE F. KOBAK, DPM, JD

oes treating diabetic pa- them. If there was a loss of the third any trend up or down in the last few tients pose challenges digit on the left foot, capillary return months. 59 in charting? Diabetes is results on the left hallux will not be Do not forget the peripheral ve- among the most com- particularly helpful. nous system. Is there edema? Bilat- mon diagnoses seen in If any part of the lower extrem- eral? Pitting? The various answers to Dpeople who sue podiatrists. Treating ities is particularly cold or warm to these inquiries suggest differing diag- diabetic patients, which almost all of the touch, record it and its specific noses. Is the edema lateral or medi- us do, substantially increases our risk location. Attempt to correlate that al? Is the edema bilateral, suggesting of being sued. All the obvious rules result with other parts of your record. a possible systemic origin? At what of charting apply. Certainly, do not An obvious example is if a toe feels level? change your chart, unless the change cold, looks blue, and has a delayed Finally, do any of the areas of the is dated, signed, and what is being capillary return; another is if a warm lower extremities look “sick”? We changed is not blacked out or delet- area of the ankle has an odor and a have all seen that digit that looks like ed. All entries should be contempora- purulent exudate. Your chart should it is about to become gangrenous. neous. If the chart is handwritten, it should be legible. We are now ready for the “Significant Seven”. It is insufficient to simply note that a 1. Peripheral Vascular neurologic examination was performed and was Examination The status of your diabetic pa- found to be within normal limits. tient’s peripheral vascular circulation is the single most often probed area by the plaintiff’s attorney in malprac- tie the various findings together, not Note it in the record. Refer appropri- tice litigation. What was the status of keep them in isolation, making oth- ately. Note any referrals in your chart the circulation when the patient first ers guess their potential significance. contemporaneously and the reason came to your office? Photographs can As for the major arteries of the for the referral. be very helpful. Today, you can use lower extremities, the pulses should a digitally dated camera to take the be palpated, comparing one extrem- 2. Neurologic Examination photos. ity with the other. “Palpable, regu- It is insufficient to simply note In your records, as well as your lar, and equal” are not enough. The that a neurologic examination was examination, distinguish between pulse in question could have been performed and was found to be with- small vessel and large vessel circula- severely diminished, yet still be pal- in normal limits. What was really tion. Capillary return, a rather simple pable, regular and equal! Use a grad- examined? Be specific. What reflex- test, is often only performed on the ing system as to the strength of the es were tested? Were they equal bi- hallucis. It should be performed on pulse being palpated. Take a note of laterally? On what part or parts of all 10 lower extremity digits and the your patient’s blood pressure. “Nor- the body was the sharp dull test per- results should be recorded for all of mal BP” is not enough. Comment on Continued on page 60

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Charting (from page 59) elicited upon dorsiflexion? Plantar- zling you or inconsistent with your flexion? Inversion? Eversion? Abduc- findings and recommendations, bring formed? Same with the vibratory re- tion? Adduction? If there are ham- it to their attention. You each might sponse. Are any areas of the lower mertoes, are they flexible, semi-flex- find it very enlightening. It may also extremities numb? Which areas? ible or rigid? Is sufficient dorsiflexion have a very beneficial effect as to fu- Mapping them would be an excellent available at the ankle? Is there any ture referrals going both ways. Most idea so that you can later ascertain significant limb length discrepancy? important, your records of these phy- if areas of anesthesia or paresthesia have spread and by how much. See if this corresponds to times of greater Test results by themselves are not enough. elevation with your patient’s blood glucose. Does neuropathic pain wors- Your chart should explain how a test’s results will en upon standing, walking, or lying down? Note that in the chart. Does influence your treatment plan. the pain or burning seem to be com- ing from the lower spine? An area often forgotten in your sician contacts demonstrate that you, 3. Dermatologic Examination records is the subject of shoe wear as the podiatrist, were aware of the A thorough examination of the patterns. Unless the patent is wearing “big picture” while treating your pa- skin of the lower extremity is of the new shoes, the shoe wear patterns tient’s feet and ankles. utmost importance in the diabetic pa- act as a type of time-action video in tient. Often, there is a decubitus ul- recording how a person ambulates. 6. Consultations ceration unknown to the patient, as Is there scuffing on the upper of a It is important to refer diabetic pa- 60 the area is numb and not easily visible shoe? Is the lateral aspect of the heel tients for vascular evaluations. More to the patient due to location or poor worn out? Significant wearing down than being good defensive medicine, vision secondary to diabetic retinopa- under the first metatarsal? Since all it is good medicine. The vascular spe- thy. Any dermatologic abnormalities these findings, especially in a diabet- cialist will be happy to discuss his or must be noted as to size and depth as ic, could and should significantly af- her findings with you. Request the well as location. Note the same from fect your treatment plan, it should be consult in writing, and why the pa- visit to visit. Record areas of dry skin, recorded in your patient’s podiatric tient needs a consult. Get the results hypo- and hyper-pigmented skin. Note medical record. of the consult in writing and place areas of erythema, edema, or cyano- it in your records. If you are using sis. Take photographs of pre-ulcer- 5. Primary Care Provider electronic medical records, scan the ations, ulcerations, darkened areas Contact the patient’s primary care consultation letter into your EHR. due to hydrostatic pressure, irritated provider as well as her endocrinol- With the patient’s permission, obtain records from their nephrolo- gist, if they have one. If the patient An area often forgotten in your records has “diabetic kidney disease”, this can influence your prescriptions. is the subject of shoe wear patterns. Obtain records from their ophthal- mologist. Know your patient, med- ically. Keep a copy of these records areas, and even “normal” base-line ogist. You must know what is and within your records. Comment in photographs of the extremities. Com- isn’t being done by the healthcare your chart about anything in these ment on the photos within the body of providers that are responsible for other records that you feel may be your records. treating their diabetes. Are they diet particularly relevant to your treat- controlled? Insulin dependent? Has ment of this patient. A last point… 4. Biomechanical Examination their dosage been going up? Exer- if your patient does not have a pri- Remember that the biomechanics cise regimen? What about the pa- mary care provider treating their di- of a diabetic, due to peripheral neu- tient’s compliance with their diabetic abetes, refer them to a primary care ropathy, may markedly differ from doctor’s treatment plan? What about provider or an endocrinologist. Note that of your other patients. However, YOUR compliance with their diabet- this in your records. do not assume it does. Test all the ic doctor’s treatment plan? Record joints of the lower extremities for any correspondence or phone con- 7. Test Results degenerative changes, crepitus, and versation with the patient’s diabet- Test results by themselves are range of motion. It is not enough to ic healthcare provider(s). Alert this not enough. Your chart should ex- simply state reduced range of motion physician of your findings. Cooperate plain how a test’s results will in- left foot. Which joint or joints have a with this physician to enhance your fluence your treatment plan. If you reduced range of motion? How much patient’s care. If something about the have performed or obtained the re- is that motion reduced? Was pain physician’s treatment plan is puz- Continued on page 62

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Charting (from page 60) someone else as opposed to read- the suggestions in the “significant ing films all day. They may impart seven” areas and you will not only sults of a peripheral arterial Dop- advice that is not readily apparent significantly reduce your legal expo- pler scan, or an x-ray, CT scan, or in their written report. Please note sure, but you will also be practicing any other test, it is insufficient to this conversation in your chart. The better, more detailed podiatric med- simply keep a copy in the chart. same advice goes for patients that icine. That is a win for podiatry and Do not forget to perform culture you send to a vascular laboratory that is a win for our patients. PM and sensitivities if purulent exudate for testing. is seen. Make sure to note in the chart that the prescription you are Conclusion Dr. Kobak is Senior Counsel in Frier Levitt’s writing is consistent with the C&S Plaintiffs’ attorneys use the de- Healthcare Depart- results. Never hesitate to biopsy ficiencies in the physician’s records ment in the Uniondale, when in any doubt. It is important to hurt them in court. Most pre- New York. Larry has to comment in the body of your fer records that are sparse, non-de- extensive experience patient notes on the test results tailed, and with no rhyme or rea- representing physicians and how the result will or will not son. The purpose for tests is not in connection with change or modify your treatment explained and the results of the licensure issues, as well plan. If the test you ordered or per- tests and the significance of exam- as successfully defend- formed was of no relevance, it was ination findings are ignored. The ing physicians before Medical Boards, OPMC, not medically necessary! results of a treatment plan, if there OPD investigations, as well as Medicare Fraud, Fraud & Abuse, Hospital Actions, RAC Audits, When you order radiologic is a treatment plan, are often over- Medicare Audits, OIG Fraud, Health Care exams, be kind to the radiologist looked in the chart. Lack of patient Fraud, Medical Audits, and Health Plan Billing and let them know what you might cooperation is often not sufficiently Audits. As a licensed podiatrist prior to becom- 62 be looking for. Do not hesitate to documented. The plaintiffs’ attor- ing an attorney, he served as the international confer with the radiologist. Often, neys love bare-bone patient histo- president of the Academy of Ambulatory Foot they will be quite pleased to talk to ries. Why give it to them? Follow and Ankle Surgery.

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