[3 MIN READ]
Patients with abdominal pain are a common and constant challenge to practitioners in primary care, pediatrics, urgent care, and emergency medicine. During the period of 2006 to 2014, there was a 32% increase in ED visits for the complaint of abdominal pain, so that as of 2014, abdominal pain is the most frequent diagnosis for an ED visit. The clinical presentations may be confusing; the differential diagnoses for abdominal pain are myriad; and not all patients with abdominal pain will have a serious underlying etiology.
Medical errors and litigation involving the care of patients with abdominal pain are all too frequent and can be costly for both patients and physicians. The cornerstone of high-quality, defensible care consists of a systematic approach coupled with compulsive documentation. The essence of liability reduction in the care of patients with abdominal pain is to construct a medical record that provides a thorough, clear and logical explanation for your thoughts and actions. Here are a few key items to address in the chart documentation.