NU 480 Unit 4 liability exposure review example

One Epigastric Complaint, No ECG: A Liability Exposure Review of a Primary Care Decision

Student Name

Department of Nursing, Herzing University

NU 480: Dimensions of Advanced Nursing Practice

Instructor Name

February 10, 2026

One Epigastric Complaint, No ECG: A Liability Exposure Review of a Primary Care Decision

The Encounter and the Decision

During my clinical rotation in a Florida primary care clinic, I observed a visit handled by an experienced family nurse practitioner, whom I will call the practitioner. Details are altered and combined so that no patient or clinician can be identified. A 52-year-old man came in on a Tuesday afternoon with two weeks of burning discomfort in the upper abdomen, worse after large meals and at night, partly relieved by antacids. He said he had no chest pain and no shortness of breath. He smoked a pack a day, had hypertension treated with lisinopril, and his father had a heart attack at 58. His blood pressure was 146/90, heart rate 84, and his exam was normal apart from mild epigastric tenderness. The practitioner diagnosed gastroesophageal reflux, prescribed omeprazole, advised smaller meals and smoking cessation, and scheduled follow-up in four weeks. No electrocardiogram was done. Two days later, the patient arrived at an emergency department with a non-ST-elevation myocardial infarction.

The decision under review is the choice not to obtain an electrocardiogram or consider a cardiac cause more actively. This review asks what the record shows, which standard applies, and how the exposure would be divided, not whether the practitioner is a bad clinician.

What Was Known at the Time

At the moment of the decision, the practitioner had a plausible gastrointestinal explanation: burning, meal-related discomfort relieved by antacids. Against that, the patient had three cardiac risk factors, smoking, hypertension, and a first-degree relative with early heart disease, and he was a man in his fifties with new upper abdominal discomfort. The current chest pain guideline defines chest pain broadly, to include discomfort in the upper abdomen as well as the chest, and advises against labeling such symptoms atypical in a way that discounts a possible cardiac cause (Gulati et al., 2021). An office electrocardiogram was available in the clinic and takes minutes.

It would be hindsight to say the infarction was obvious. It would not be hindsight to say that a cardiac cause belonged on the differential for this patient, because every fact supporting it was known at the visit.

What the Record Shows

An outside reviewer would read the note, not the practitioner's memory. The note documents the history of burning discomfort, antacid relief, "denies chest pain," the vital signs, the exam, and the plan. It does not document a differential diagnosis, whether exertional symptoms were asked about, any cardiac risk assessment, why an electrocardiogram was not needed, or return precautions for chest pain, shortness of breath, or worsening symptoms. The risk factors appear only in the past medical and social history, copied forward from an earlier visit.

The gaps matter as much as the decision. If the practitioner considered a cardiac cause and judged it unlikely for stated reasons, a note saying so would show a reasoned judgment, which a reviewer can disagree with but must respect. Without it, the record suggests the possibility was not considered at all. The missing return precautions are a separate weakness: a patient told to return for chest pain or breathlessness might have come back a day sooner.

What a Defensible Note Would Have Said

Even if the practitioner had made the same decision, a few sentences would have changed how the record reads. For example: "Differential includes GERD, peptic ulcer disease, biliary disease, and cardiac ischemia given smoking, hypertension, and family history. Discomfort is burning, postprandial, relieved by antacids, not exertional, no associated dyspnea or diaphoresis. ECG obtained: normal sinus rhythm, no acute changes. Will treat as GERD. Patient instructed to call 911 for chest pressure, pain with exertion, shortness of breath, or sweating, and to return in one week if not improved." That note documents a reasoned judgment, a test that took five minutes, and instructions that give the patient a way back.

The Standard Against Which the Decision Is Measured

In Florida, the standard in a medical negligence claim is the level of care, skill, and treatment that reasonably prudent similar health care providers recognize as acceptable and appropriate in light of all relevant surrounding circumstances (Fla. Stat. § 766.102, 2025). For this practitioner, the comparison group is family nurse practitioners in primary care, not cardiologists. Experts would be asked whether a reasonably prudent family nurse practitioner, seeing this patient, would have considered a cardiac cause and obtained an electrocardiogram or referred him for evaluation. Given the risk factors, the availability of the test, and guideline language about upper abdominal symptoms, I think many would say yes, although reasonable experts could disagree. A negligence claim would also require showing that an electrocardiogram on Tuesday would probably have changed the outcome; an initial tracing can be normal in a non-ST-elevation infarction, which is one reason causation might be contested.

How the Exposure Divides

The practitioner. Personal liability for her own judgment and documentation. Nurse practitioners are named in malpractice claims in their own right, and a review of nurse practitioner payment reports in the federal practitioner database found diagnosis-related allegations among the most common (Miller, 2011). Her license is a separate exposure: the Board of Nursing can review the care regardless of any lawsuit.

The employer. The health system that employs her would likely be vicariously liable for her acts within the scope of employment, and its malpractice policy would ordinarily defend her. The system also has its own exposure if its policies, such as schedules that allow 15 minutes for a new complaint, contributed.

The supervising physician. Under Florida's protocol-based practice, a plaintiff might also name the supervising physician, alleging inadequate supervision or protocol. That exposure depends on what the protocol required and whether the physician was consulted; here, she was not.

What I Take From This for My Own Practice

Three habits. Document my differential diagnosis, especially the serious possibilities I considered and why I judged them less likely, in one or two sentences. Give and document specific return precautions for any complaint in which a dangerous diagnosis is possible. And treat upper abdominal symptoms in a patient with cardiac risk factors as possibly cardiac until I have a reason not to, since an office electrocardiogram costs little compared with a missed infarction. Before my first job, I will also confirm the type of malpractice coverage the employer provides and whether it covers me after I leave.

References

Fla. Stat. § 766.102 (2025).

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., ... Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 144(22), e368-e454. https://doi.org/10.1161/CIR.0000000000001029

Miller, K. P. (2011). Malpractice: Nurse practitioners and claims reported to the National Practitioner Data Bank. The Journal for Nurse Practitioners, 7(9), 761-773. https://doi.org/10.1016/j.nurpra.2011.07.008