Failure to diagnose impending myocardial infarction
A 57-year-old man came to his internal medicine physician’s office on a walk-in basis. He reported waxing and waning chest pain for one week, with his last episode occurring that day at work.
Failure to diagnose impending myocardial infarction
A 57-year-old man came to his internal medicine physician’s office on a walk-in basis. He reported waxing and waning chest pain for one week, with his last episode occurring that day at work.
Presentation
On Friday, September 2, a 57-year-old man came to his internal medicine physician’s office on a walk-in basis. He reported waxing and waning chest pain for one week, with his last episode occurring that day at work. The patient denied being in pain at this visit. He was scheduled as the last patient of the day.
The patient’s history included hypertension, hyperlipidemia, and uncontrolled diabetes. His father’s history included a coronary artery bypass graft (CABG) at age 43.
The patient — who had a 3-year history with the practice — had a mixed record of medical compliance. He often did not return for follow-up appointments and did not follow treatment recommendations to properly control his diabetes. He had previously been hospitalized for chest pain.
Physician action
The patient reported chest burning, squeezing, and tightness with diaphoresis and dyspnea to the clinic’s physician assistant (PA). The patient said his symptoms were aggravated with exertion and relieved with rest. The duration of episodes had increased over the past week, lasting up to 15 minutes per episode.
The PA obtained an electrocardiogram (EKG) that showed the patient had a normal sinus rhythm with non-specific ST-T wave changes. The patient denied radiation of pain, palpitations, numbness, tingling, or any neurological deficits. He also denied a history of anxiety or acid reflux and stated that he had never experienced this pain before.
The PA recommended the patient go to the ED, but the patient declined because he wanted to go home to have dinner with his family. The PA ordered a chest X-ray and provided a referral to a cardiologist for a stress test. The patient was instructed to go immediately to the ED if he had another episode.
The next morning, the patient collapsed at home and his wife called 911. He was transported by EMS with CPR in progress to a local hospital. The patient died shortly after arriving at hospital.
The patient’s internal medicine physician was asked to sign the death certificate. She signed and reported the patient’s immediate cause of death as “diabetes mellitus with underlying causes of hypertension and hyperlipidemia.”
The PA added the patient’s September 2 visit notes and refusal to go to the ED to the patient’s medical record on Monday, September 5.
Allegations
A lawsuit was filed against the PA and the internal medicine physician. Allegations included failure to diagnose and treat an impending myocardial infarction (MI).
Legal implications
Two internal medicine consultants who reviewed this case for the defense believed the patient came to the PA with symptoms suggestive of coronary ischemia. These symptoms, in addition to multiple cardiac risk factors, should have led the PA to immediately refer the patient to the ED. Had the patient gone to the ED, he would likely have been admitted for a thorough cardiology evaluation; serial EKGs and cardiac enzyme testing; stress testing; and, if required, catheterization.
Consultants for the plaintiff were critical, expressing that this patient should have been immediately taken to the ED for evaluation. One consultant stated that the PA should have more forcefully informed the patient of the risks of noncompliance and insisted on emergent transfer to the nearest ED.
The PA testified that the patient was not experiencing chest pain during the visit, and the EKG was normal without any concerning ST changes to indicate either acute MI or unstable angina. However, this testimony was not supported by contemporaneous documentation.
The PA also testified that while the internal medicine physician was not at the office during the patient’s visit, the physician was readily available and could have been easily reached if the PA had a question or concern about the patient.
The internal medicine physician testified that she was informed of the patient’s death after the fact. Before signing the death certificate, she reviewed the patient’s medical record and found it to be incomplete. The record was missing the visit notes from the Friday, September 2, office visit.
Disposition
This case was settled on behalf of the PA. The case against the internal medicine physician was dismissed.
Risk management considerations
The defense of this case was compromised by the PA’s failure to document the patient’s visit on September 2. The PA’s testimony, along with some expert opinions, suggested that the PA treated this patient appropriately and met the standard of care. Yet the PA failed to document the care provided when it occurred, which might have caused a jury to speculate on whether the defense was credible.
Had the patient’s visit been fully, accurately, and contemporaneously documented, there would have been a clear record of what transpired between the patient and provider. In this case, the medical record was updated after the patient’s death, which could lead those reviewing the record to question its validity.
In addition to the visit notes, it would have helped the defense if the PA had documented the patient’s informed refusal or noncompliance with recommendations to go to the ED. As with informed consent, it is important to document when a patient refuses to follow a provider’s professional recommendations or instructions.
When documenting informed refusal, include test results; treatment discussed or offered; reasoning behind treatment offered; conversations with the patient, including risks of noncompliance; conversations with other providers and specialists; the patient’s refusal of care and reasoning; and the patient’s mental status and decision-making capacity. Request the patient sign the note or statement of informed refusal.
Depending on the circumstance, consider using an informed refusal form for your practice. If a patient's refusal could lead to severe or permanent injury or death, use of this form may help you clearly document the refusal. Also, asking a patient or guardian to complete or sign the form may reinforce the seriousness of the situation to an indecisive patient or guardian and help them to reconsider. (1)
Source
- Wenske W. Avoiding common documentation errors. The Reporter. Quarter 1, 2024. Texas Medical Liability Trust. Available at https://www.tmlt.org/resource/cme-avoiding-common-documentation-errors. Accessed February 3, 2026.
More about documentation errors
Risk management for adult primary care physicians
Disclaimer
Presentation
On Friday, September 2, a 57-year-old man came to his internal medicine physician’s office on a walk-in basis. He reported waxing and waning chest pain for one week, with his last episode occurring that day at work. The patient denied being in pain at this visit. He was scheduled as the last patient of the day.
The patient’s history included hypertension, hyperlipidemia, and uncontrolled diabetes. His father’s history included a coronary artery bypass graft (CABG) at age 43.
The patient — who had a 3-year history with the practice — had a mixed record of medical compliance. He often did not return for follow-up appointments and did not follow treatment recommendations to properly control his diabetes. He had previously been hospitalized for chest pain.
Physician action
The patient reported chest burning, squeezing, and tightness with diaphoresis and dyspnea to the clinic’s physician assistant (PA). The patient said his symptoms were aggravated with exertion and relieved with rest. The duration of episodes had increased over the past week, lasting up to 15 minutes per episode.
The PA obtained an electrocardiogram (EKG) that showed the patient had a normal sinus rhythm with non-specific ST-T wave changes. The patient denied radiation of pain, palpitations, numbness, tingling, or any neurological deficits. He also denied a history of anxiety or acid reflux and stated that he had never experienced this pain before.
The PA recommended the patient go to the ED, but the patient declined because he wanted to go home to have dinner with his family. The PA ordered a chest X-ray and provided a referral to a cardiologist for a stress test. The patient was instructed to go immediately to the ED if he had another episode.
The next morning, the patient collapsed at home and his wife called 911. He was transported by EMS with CPR in progress to a local hospital. The patient died shortly after arriving at hospital.
The patient’s internal medicine physician was asked to sign the death certificate. She signed and reported the patient’s immediate cause of death as “diabetes mellitus with underlying causes of hypertension and hyperlipidemia.”
The PA added the patient’s September 2 visit notes and refusal to go to the ED to the patient’s medical record on Monday, September 5.
Allegations
A lawsuit was filed against the PA and the internal medicine physician. Allegations included failure to diagnose and treat an impending myocardial infarction (MI).
Legal implications
Two internal medicine consultants who reviewed this case for the defense believed the patient came to the PA with symptoms suggestive of coronary ischemia. These symptoms, in addition to multiple cardiac risk factors, should have led the PA to immediately refer the patient to the ED. Had the patient gone to the ED, he would likely have been admitted for a thorough cardiology evaluation; serial EKGs and cardiac enzyme testing; stress testing; and, if required, catheterization.
Consultants for the plaintiff were critical, expressing that this patient should have been immediately taken to the ED for evaluation. One consultant stated that the PA should have more forcefully informed the patient of the risks of noncompliance and insisted on emergent transfer to the nearest ED.
The PA testified that the patient was not experiencing chest pain during the visit, and the EKG was normal without any concerning ST changes to indicate either acute MI or unstable angina. However, this testimony was not supported by contemporaneous documentation.
The PA also testified that while the internal medicine physician was not at the office during the patient’s visit, the physician was readily available and could have been easily reached if the PA had a question or concern about the patient.
The internal medicine physician testified that she was informed of the patient’s death after the fact. Before signing the death certificate, she reviewed the patient’s medical record and found it to be incomplete. The record was missing the visit notes from the Friday, September 2, office visit.
Disposition
This case was settled on behalf of the PA. The case against the internal medicine physician was dismissed.
Risk management considerations
The defense of this case was compromised by the PA’s failure to document the patient’s visit on September 2. The PA’s testimony, along with some expert opinions, suggested that the PA treated this patient appropriately and met the standard of care. Yet the PA failed to document the care provided when it occurred, which might have caused a jury to speculate on whether the defense was credible.
Had the patient’s visit been fully, accurately, and contemporaneously documented, there would have been a clear record of what transpired between the patient and provider. In this case, the medical record was updated after the patient’s death, which could lead those reviewing the record to question its validity.
In addition to the visit notes, it would have helped the defense if the PA had documented the patient’s informed refusal or noncompliance with recommendations to go to the ED. As with informed consent, it is important to document when a patient refuses to follow a provider’s professional recommendations or instructions.
When documenting informed refusal, include test results; treatment discussed or offered; reasoning behind treatment offered; conversations with the patient, including risks of noncompliance; conversations with other providers and specialists; the patient’s refusal of care and reasoning; and the patient’s mental status and decision-making capacity. Request the patient sign the note or statement of informed refusal.
Depending on the circumstance, consider using an informed refusal form for your practice. If a patient's refusal could lead to severe or permanent injury or death, use of this form may help you clearly document the refusal. Also, asking a patient or guardian to complete or sign the form may reinforce the seriousness of the situation to an indecisive patient or guardian and help them to reconsider. (1)
Source
- Wenske W. Avoiding common documentation errors. The Reporter. Quarter 1, 2024. Texas Medical Liability Trust. Available at https://www.tmlt.org/resource/cme-avoiding-common-documentation-errors. Accessed February 3, 2026.
More about documentation errors
Risk management for adult primary care physicians
Disclaimer
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