Documentation

This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 15, with the permission of the Editor, for ease of viewing on mobile devices.

Although as important as verbal communication skills, written documentation is unfortunately understressed in many clinical areas. The medical record allows us to communicate with our colleagues and can provide a glimpse into the caregiver’s thought process. Traditionally, entries in the medical record are handwritten. However, depending on the resources and system used at your particular facility, the “emergency department treatment record” may be dictated and transcribed or computer generated. Some institutions may use a complaint-based templated charting system (either handwritten or electronic) to promote accurate documentation. An advantage of templated charting systems is that they prompt the caregiver to answer patient-related questions that may enhance and streamline the coding and billing process. A disadvantage or limitation of the pure templated chart is that it is mostly a checkbox and slash documentation tool that provides little opportunity for the care provider to document in paragraph form his or her thought process. When a templated chart is reviewed days or weeks later, it may be difficult to get a true sense of the patient presentation. An example of a templated emergency department chart for a complaint of chest pain can be found at http://www.tsystem.com/library/ media/images/sample-ep-chest-pain-front.jpg.

The medical record should be used to document the patient’s encounter with the goal of communicating your thought process in a manner that can be helpful to future practitioners caring for that particular patient.

Handwritten charts have their advantages and disadvantages. The main advantage of a handwritten chart is the ability to document in the medical record in real time at the bedside as care is being provided. The chart can be completed in parallel to providing patient care. However, a number of limitations exist with handwritten charts; first and foremost is legibility. Illegible or confusing handwriting by clinicians in addition to the use of dangerous medication abbreviations has been shown to be an underlying factor associated with many medication errors. Another limitation can be the variability of thoroughness or completeness of the medical record. With handwritten charts, the depth of the documentation is very dependent on the practitioner. Some practitioners will take the approach of documenting the minimum necessary information to achieve a particular billing level or to convey the pertinent facts of the case. Time constraints also may affect the depth of documentation. Brief or minimal documentation does not necessarily reflect a lack of attention to detail.

Regardless of the method of documentation used to complete the emergency department treatment record, the principles of documentation are the same. The medical record should be used to document the patient’s encounter with the goal of communicating your thought process in a manner that can be helpful to future practitioners caring for that particular patient. Each encounter should be documented and at a minimum contain pertinent elements of the H&PE, assessment, and plan. This is the “SOAP note” format (subjective, objective, assessment, plan). Your approach to completing the medical record should mirror your approach to performing the H&PE—focused but thorough. However, as a medical student, documentation in the medical record, specifically in the emergency department, may be limited because of guidelines set forth for teaching physicians by the Centers for Medicare and Medicaid Services. These guidelines can be viewed at http://www.cms.hhs.gov/MLNProducts/downloads/ gdelinesteachgresfctsht.pdf.

It is important that the emergency department treatment record reflect the full extent of the evaluation and treatment performed in the emergency department.

A brief review of these guidelines follows. A medical student may document services in the treatment record; however, the teaching physician may refer only to the student’s documentation of an evaluation and management service that is related to the ROS and past medical, family, and social history. The teaching physician must verify and document the HPI, the physical examination, and the medical decisionmaking process. These guidelines do not necessarily curtail the degree of involvement that students have with a patient or limit their autonomy. Although your ability to document in the emergency department treatment record may be limited, your understanding of the importance of proper documentation is nonetheless essential. Please check with your clerkship director to clarify the documentation guidelines for the particular clinical site to which you are assigned. A template H&PE form that you can use for your emergency department patient encounters is included at the end of this section.

Remember the time honored saying, “If it isn’t documented, it didn’t happen.”

It is important that the emergency department treatment record reflect the full extent of the evaluation and treatment performed in the emergency department. Remember that the patient’s chart contains more than just the physician’s note. It contains other equally important elements, such as registration data, nursing notes and assessments, and prehospital run sheets, if applicable. You also have the added responsibility of reviewing this information, specifically nursing and prehospital notes, for accuracy or any discrepancies. The following are a few helpful hints for documentation:

  • Date and time all of your notes in the medical record.
  • Write your notes legibly.
  • If you make a mistake, draw one line through it and sign your initials.
  • Document a focused but thorough H&PE.
  • Document vital signs and address abnormalities.
  • Document the results of all diagnostic tests you have ordered.
  • When you speak to a consultant, document name and times.
  • Document the patient’s response to therapy.
  • Document repeat examinations.
  • Document your thought process (medical decisionmaking).
  • Never write derogatory comments in the medical record.
  • Never change or add comments to the medical record after the fact. It may be appropriate to add an addendum, but only if it is properly timed and dated.
  •  Document your procedures.
  • If a patient leaves AMA, document that you have explained the specific risks of leaving AMA.
  • Document plans for outpatient care and follow-up.

Last, in the event of an unanticipated bad outcome, patient complication, or death, the chart in its entirety may be reviewed in a peer-review process or in a malpractice suit if the case proceeds to litigation. In these situations, your documentation serves as your main defense. Remember the time honored saying, “If it isn’t documented, it didn’t happen.” Keep in mind that, at times, you may have a difference of opinion with a colleague or a less-than-professional interaction with a consultant. If this occurs, it is never acceptable to use the medical record to fight with colleagues—the so called “chart wars.” If a consultant is not answering a page, simply note, “At the time of this dictation, Dr. XXX has not called back.” Similarly, if you disagree with a consultant’s plan, document this using nonjudgmental language. It can also be helpful to record the specific times of certain events in complicated cases or to add addendum notes if the condition of the patient changes or if the patient is in the emergency department for an extended period of time.

Adherence to coding and billing guidelines will also influence documentation. Although a review of these guidelines is beyond the scope of this Primer, recognize that patients are billed according to the complexity of their visit. To substantiate this billing, there must be enough documentation of the H&PE and medical decisionmaking elements to support the level of care provided.

Although you are developing your own personal style of documentation, consider who will be potentially reading your chart (e.g., other medical students, billing personnel, nurses, residents, attendings, and possibly lawyers). By doing so, it will become more clear what your documentation should and should not consist of. In addition, you should never write anything in the medical record that you would be uncomfortable having shown to a jury. Although it might seem like an added burden at times, especially during a busy shift, proper documentation is of paramount importance.

Suggested Reading

  • Center for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, and Residents. Washington, DC: Department of Health and Human Services; 2007. Available at: http://web.msm.edu/compliance/ TPguidelines.9.06.pdf. Accessed March 6, 2008.
    • This document outlines documentation guidelines for physicians in a teaching setting who are paid under the Medicare Physician Fee Schedule.