Emergency department (ED) documentation is unique because it is the only account of a patient’s ED visit and is completed under strict time constraints. As charting takes away from focus on patient care, physicians can rely on emergency room transcription services to ensure accurate, detailed and timely capture of the patient encounter. Accurate and thorough patient chart information is crucial for further communication between healthcare professionals involved in patient care in hospital and also upon discharge.
Importance Of Proper ED Charting
ED physicians need to have a clear understanding the purposes of ED charting:
- Official Record – The ED chart is the official record of the physician-patient encounter, H&P, and diagnostic and treatment plans.
- Communication – To provide the best patient care, healthcare providers who see the patient later need complete and accurate information about what was done in the ED.
- Billing – The nature of the actions performed in the ER should be clearly documented to justify the level of billing reported.
- Medicolegal Defense – The chart should prove adherence to a high standard of care to serve as a defense in the event of a malpractice suit.
Good, clear ED charting is also critical for quality improvement reviews, research and utilization/risk management.
Requirements For ED Documentation
There are several reasons why ED charting is unique and distinct from other physician notes. The ED note is a stand-alone completed under tight time pressures. The physician needs to focus being brief while conveying as much information as possible for present and future care. Though the medical decision-making process is based on limited information, the chart should show all differential diagnoses.
The ED note should include everything that is relevant to the patient’s complaint including the subjective, objective, assessment and plan (SOAP) portions. Here are the four key elements that the ED note should contain as listed by the Society for Academic Emergency Medicine (SAEM).
- Subjective Portion
The subjective section should cover:
- The patient’s presenting/chief complaint or the reason why the patient is medical care as stated by the patient.
- The history of present illness (HPI) – the main aspects of a symptom of the chief compliant (like pain): onset, location, quality, severity, timing/frequency, alleviating factors, and aggravating factors (OPQRST).
- Over-the-counter and prescriptions medications, and any medication allergies.
- For patients with more chronic problems – compliance with any medications or medication side effects, current symptoms or complications, end organ effects, and any health care needs related to the chronic illness.
- Objective Section
The adage: “if you didn’t document it, then you didn’t do it” applies to this section.
- Include everything observed or measured during the interaction with the patient.
- Use standard medical language or commonly accepted abbreviations to report vital signs, general appearance, the relevant physical examination, and any laboratory or imaging results.
- Thorough physical examination documentation
- Results of any laboratory or radiologic studies ordered during the visit
- Assessment Section
The medical decision-making process is recorded in this section. Documentation comprises the following:
- Summary Statement – concise summary of the chief complaint along with main elements of the subjective and objective sections
- Problem List – details of all problems
- Discussion of Differential Diagnosis – brief account of a probable differential diagnosis for each acute problem on the problem list
- Plan Section
Each section of plan of action for the patient should be based in three things:
- Diagnostic recommendations – observation, laboratory tests, radiologic imaging, ECGs, or other diagnostic procedures
- Treatment options – medications and therapeutic procedures
- Follow-up plans – clear follow-up plan for future care
Role Of Emergency Room Transcription Services
Emergency medicine practice involves multitasking to deal with complex clinical problems and there is no doubt regarding the need for accurate and detailed medical documentation. Complete and accurate ED documentation shows all differential diagnosis, high-risk conditions, and medical decision making. However, some template-based software may be limited and can lead to inaccuracies and errors in the physician’s narrative. The solution is to add free text using dynamic templates, dictation, and medical transcription.
In 2017, the American Medical Association (AMA) reported on a study published in the Annals of Emergency Medicine that analyzed the effectiveness of electronic documentation in the ED. The lead author Joshua Feblowitz, MD noted: “The emergency department is a fluid and highly dynamic environment, with high volume, sick patients and frequent distractions and interruptions. The implementation of EHRs holds great promise in the emergency setting, but the environment is especially susceptible to changes that influence efficiency”.
The AMA report referenced Dr. Feblowitz, an emergency medicine resident at Brigham and Women’s Hospital and Massachusetts General Hospital as saying that adopting new workflow strategies and technologies can improve the efficiency of documentation in the emergency department. According to Dr. Feblowitz, the use of scribes and electronic dictation software are two specific interventions that have the potential to improve completeness and efficiency of documentation.
By capturing all aspects of differential diagnosis and medical decision making, an experienced emergency medical transcription service provider can help ED physicians ensure thorough and accurate ED documentation as they focus on providing the best patient care.