This month we look at a case in which a nurse’s careful documentation of a patient’s neurologic examination findings saved the day for a hospital that had been sued.

Ms L, 28, worked as a nurse in the emergency department of a large hospital in a metropolitan area. She had been working at the hospital for 2 years and was considering going back to school for her advanced practice degree. The nurse particularly enjoyed working with children and hoped to eventually move to the pediatrics department.

She was working one Monday morning when Jane, a 14-month-old child, was brought in by her mother and grandmother. The mother told Ms L that Jane had a fever of 100 degrees and had been vomiting for the past 2 days, including 5 times the previous night.

“Also,” mentioned the grandmother, “Jane has a bump on her left knee. She had been walking before, but a few days ago she stopped walking.”

Ms L performed an initial assessment and noted that Jane was awake, alert, fussy, hard to console, and was vomiting clear fluid during the examination. Ms L conducted a neurologic examination on the child and found that her responses were within the defined parameters. Ms L noted everything in the patient’s file and then introduced the family to Dr S, the emergency department physician.

Dr S examined Jane and noted that she appeared acutely dehydrated, was fussy, and had dry mucous membranes. He looked at the bump on her left knee and measured it as 1 cm in diameter. The physician noted that Jane refused to put her legs down when put down to see if she would walk. He ordered a laboratory assessment, which revealed only dehydration, and a radiographic examination of the child’s left knee, which revealed no fracture or abnormality. The physician diagnosed Jane with gastroenteritis and dehydration and ordered intravenous hydration and ondansetron for nausea. The child’s condition improved, and she was later discharged with a prescription for ondansetron and instructions to return to the emergency department if the vomiting returned.

The next day, Ms L was surprised to see Jane back in the emergency department with her mother. Jane’s mother reported that the child had continued vomiting after returning home the previous day and that she would not take the ondansetron.

Again, Ms L conducted an examination. She found Jane to be awake, alert, and oriented to her mother, and she noted that the child was fussy but easily consoled by her mother. Ms L noted that the child was not listless, and she stood on the scale with no difficulty. She conducted a neurologic examination and noted in the chart that the results were again within normal parameters.

Another emergency department physician, Dr G, examined Jane this time and ordered intravenous hydration and ondansetron. The child remained in the emergency department overnight and on Wednesday morning was admitted to the pediatric department with a chief complaint of dehydration and vomiting. Shortly after admission, the child suffered from profound neurologic deterioration, followed by acute respiratory failure. Computed tomography of the child’s head revealed a brain tumor and massive cerebral edema. A pediatric neurosurgeon performed ventriculostomy to relieve pressure on the brain followed by craniotomy to remove the tumor. Although Jane recovered from the surgery, she suffered permanent neurologic impairment.

Her distraught parents sought the counsel of a plaintiff’s attorney, and they filed a lawsuit against the hospital and physicians alleging that the treatment of Jane in the emergency department fell below the standard of care and that she suffered additional brain damage or loss of a better chance of recovery due to the substandard care.