Abscess management does not end when the pus is out. The chart you write is what protects you weeks or months later when something goes wrong. Module 5 of The Abscess Course walks through this in detail. Here are the highlights.
Most legal exposure around skin infections comes from failure to diagnose or failure to treat. To diagnose it, you have to consider it. To consider it, you have to look. The patient was wearing jeans is not a defense. Get the patient undressed and examine the area in question.
Document the history. Comorbidities, medications, prior abscesses, IV drug use, immunocompromised status. These belong in the chart, not just in your head.
Document your medical decision making. Why you chose the antibiotic. Why you did or did not pack. Why you did or did not send to the ED. The reasoning is what supports the chart, not the procedure note alone.
Document return precautions in writing. Fever, spreading redness, worsening pain, new fluctuance. The patient should leave with both verbal instructions and a printed summary.
Module 5 covers all of this with templates.
Full course at: https://www.ebmedicine.net/the-abscess-course
Sincerely,
Dr. Patrick O’Malley
The Abscess Course & The Laceration Course, Course Director
Patrick O’Malley is an emergency physician and course director of The Laceration Course and The Abscess Course. Follow him bellow for more…
