One of the best risk management strategies is clear discharge instructions. 

• Estimated that half of lawsuits in EM are related in someway to discharge planning. 

Instructions should be time specific and action specific and include what to return to the ER for. 

The more that is listed the less that is read; the pre made templated instructions are never a substitute for verbally closing the encounter. 

Use the concept of "preemptive strike" - explaining what may happen early in the patient encounter. 

• Example: If a patient comes in after a car accident with glass in a wound you should tell the patient it's possible not all of the glass was removed and so if they see glass being expressed from the wound at a later time they know you're not so sloppy that you missed it but so smart that you knew this may happen and told them what to do about it. 

Avoid "false certainties" 

• Be careful with putting the "EM diagnoses of exclusions" on the chart like gastroenteritis, GERD, anxiety, panic attack, migraine, etc.
• An important skill in Emergency Department discharge is telling the patient you do not know what is wrong with them - communicate to the patient that a diagnosis is not always made in the Emergency Department. 
• A key corollary to this is avoiding the statement: "there is nothing wrong with you". This may disincentive adherence to discharge planning and if something significant is missed, may increase the likelihood of a lawsuit. 
• Example: You have a patient with periumbilical abdominal pain, nausea, vomiting and diarrhea and you suspect a viral gastroenteritis; you can tell the patient you think this is a stomach bug but warn them that if the pain localizes to the RLQ or does not improve/ resolve after 8-12 hours to return for a re-examination. 

Do your reassessment note in real time.

• This should be the time where you use your reassessment note as a time to run through the case and any high risk features, run through the can't miss differential diagnosis of your patient's complaint, and an opportunity to document why you thought the patient was safe to be sent home. 
• 2 exams on the medical record are better than 1 - repeat your abdominal exam/ other focused exam and document changes in patient conditions after an intervention. 
• Anytime you do anything to a patient you have to be prepared to interpret the result and document your interpretation (this includes vital signs and exam findings on top of labs, imaging, etc.) 
• Any shared decision making should be documented. 
• Asking for and documenting patient's and families understanding and comfort with discharge planning has been shown to reduce liability and risk of getting sued. 
• Empower family or friends with the patient to check in on the patient, especially in the head injury patients. 

Put together a discharge program that the patient can complete. 

• Any social barriers should be anticipated early so that social work can help and so as not to delay the disposition. 

Discharge Instruction Pearls:

• When a patient says "They did not do anything" it usually means what was done on a prior ER visit was not communicated well to them and there was a failure in discharge planning. 
• Time is the best test in medicine - this sentiment needs to be communicated to patients with diagnostic uncertainty and use this to guide your patient's follow up time. 
• Make the bounceback a sign of great discharge instructions. 
• Can't walk, can't go home. 

References:

Weinstock, Michael B., et al. Bouncebacks!: Medical and Legal. Anadem Publishing, 2011.

Risk Management Monthly Podcast, Dr. Greg Henry, Dr. Rick Bukata, Dr. Mel Herbert.