- Authors: Todd Guth and Tom Morrissey
- Editor: Keme Carter
- Last Updated: 2015
Introduction to Medical Documentation
Why do I have to write EVERYTHING down? Why can’t I just take care of my patients? All this documenting is preventing me from doing my job!
This sentiment is not uncommon among physicians. None of us really think we shouldn’t have to document, but the statement reflects the frustration physicians have about having to devote so much time to the written record. With limited time, and a seemingly unlimited waiting room, balancing the demands of bedside care and charting can indeed be challenging. In this chapter, we hope to introduce you to the Emergency Department (ED) note, enhance your understanding of its importance and intricacies, and help you begin to build the skill set that will allow you to be an effective and efficient keeper of the ED medical record.
Goals and Objectives
At the end of this section you should be able to:
- List reasons for learning and performing good ED documentation
- Explain differences between documentation in the ED vs other hospital arenas
- Recognize different types of ED documentation systems, including the electronic health record (EHR)
- Describe the components of a good ED chart
- Formulate examples of helpful and harmful entries into the ED medical record
- Employ skills to keep you from going crazy writing in the medical record!
The purpose of the chart
Perhaps the best place to start is by considering “why” documentation is so important. The ED chart serves multiple purpose some obvious and others less so. These reasons will be referred to later as we discuss the components of a typical ED encounter.
- Communication– Very rarely is a patient doctor encounter so self limited that no one else ever needs to know about it. Our chart is the primary way that we have to communicate to other health care providers what was done in the ED. This includes not only diagnostic tests, medical decision making, and treatments, but also discussions with patients and families about their concerns and desires, discussions with consultants about recommendations, the patient’s follow-up, and many other esoteric aspects of the encounter.
- Billing– EDs run on a tight budget and are often seen as money-losers for the hospital (not really true because we bring patients into the hospital, which generates revenue for other services).
- Medicolegal Protection– In the event of a bad outcome, patient complaint or lawsuit, the chart is the final (often only) representation of what happened during the encounter. The adage of “if it wasn’t written down, it didn’t happen” has haunted many a competent and well-meaning physician. The ED record must be able to serve as our defense.
- Quality Improvement Reviews– Hospitals are always trying to improve. Review of charts is one big way that this is accomplished. Consider that items that may not seem important to you (or your patient or consultant) might be very important to reviewers interested in quality or process improvement.
- Research– Retrospective chart reviews are also frequently where good research gets started. Good clear documentation may help an investigator garner data to help devise a study that will improve care in the future.
- Utilization Management/Risk Management– The hospital administrators review the medical records to establish timelines and points of delay. Your good charting (time documentation) can give them the tools they need to fix these delays.
How the ED chart is different from other charts
None of these reasons for good charting are unique to the ED, and the items on the above list are important throughout the hospital. There are, however, some specific differences between ED notes and notes from other providers.
- Time Pressures- The ED is under tighter time constraints than most other care areas. This limits time for documentation and places a premium on efficiency (a mix of brevity and completeness…everything you need to know, nothing that you don’t). The busyness makes it hard to remember exactly what happened and when, so timely completion of charting is critical if the chart is to be accurate.
- Isolated Encounter- For us in the ED, each encounter is both a “new patient encounter” and a “final encounter” and needs to be handled as such. This means often gathering extensive pertinent past medical information, dealing with the issue at hand, and making plans for future care such as admission or follow up. Each visit needs to stand-alone completely.
- Billing Mechanics- ED visits are billed differently than most other encounters. Our charts are graded on a complexity level from 1-5, and each level has a list of minimum documentation requirements that need to be met in order to be billed. If any of these are not met, the chart gets significantly down-coded.
- Different Goals- In the ED, we must have a “think worst-first” approach to the differential diagnosis, rather than always clinching a final diagnosis. Our chart needs to reflect this thinking process.
- Patients see us differently- Unlike the PCP who has an established track record with the patient, or the admitting doc who might see the patient several times during the stay, we get one chance to make an impression. Our chart is our only way to record the impression that was made. This impression is critical if our care is questioned down the road.
As you begin your foray into ED documentation, keep these purposes and differences in mind (see Fig 1). Put yourself in the shoes of the other people who will read your chart. Make special note of things that frustrate you when you read other peoples charts. Only with focused practice you will get better and faster daily.
|Purposes of Chart||Differences from other charts|
|1) Provides communication with other health professions team members using standard medical language and abbreviations||1) Written under time and space constraints leading to an emphasis on brevity, yet must still contain all pertinent info|
|2) Serves as official record of the doctor-patient encounter, H&P, diagnostic and treatment plans||2) Written as isolated complete and isolated encounter rather than a progress note or H&P|
|3) Demonstrates your medical decision making to other health professionals||3) Medical decision making is often based on limited information. Thought processes must be explained|
|4) Provides a template for billing that documents the complexity of the visit||4) Billing: Must address components of CMS EM specific billing regulations|
|5) Serves as medico-legal protection in medical liability cases||5) Rapport: Serves as only chance to demonstrate relationship with patient and family|
Qualities of an Emergency Department Note
The ED note should paint a picture of the encounter: how it began, how it evolved (and the factors that drove that evolution), how it comes to a conclusion, and where it needs to go in the future. It should tell a story that the reader can follow easily and completely. Several note qualities are essential to maintain these high standards: completeness and accuracy, conciseness, and organization.
- Completeness and accuracy- A medical note must be complete to assure a good understanding of the interaction with the patient and the plan of care, without superfluous information. As medical students, all information may at first seem possibly relevant to the patients’ presenting complaints (and in fact it may be!). Eventually with more experience you will have a better understanding of what is most relevant to include in your written communications.
- Conciseness- When starting out, it is best to focus first on being accurate and complete, then work on being concise. One of the biggest ways to achieve conciseness is through proper organization of your written communications. This avoids duplication and meets the expectations of others health professionals reading your notes. For emergency medicine, the emphasis is on capturing the relevant details of the patient’s presentation that drive your differential diagnosis, and that help to showcase your thinking about what could be happening with the patient.
- Organization- The best students are able to calibrate their notes to reflect their thinking about the most important question in emergency medicine, “Is this patient sick or not sick?” The thought, “Does this patient have a serious, life or limb-threatening condition?” is always on the mind of the EP and must be reflected in your medical documentation. Both the type of information that you select to include in your note, and how you choose to organize it, accomplishes this task!
Structure and Components of an ED Note
The ED note may be best described as a blend between the traditional comprehensive History and Physical (H&P) note and the focused SOAP note. ED notes should err on the side of including much of the relevant information contained within a comprehensive H&P note but still need to be focused upon the patient’s presenting chief complaint. Since most patients coming into the ED are undifferentiated patients, unknown to you as a provider, you must perform a fairly comprehensive H&P to appreciate perspective of the patient before coming up with an appropriate differential diagnosis and treatment plan. On the other hand, EPs are not necessarily interested in all the different medical problems that a particular patient might have; they are interested in why that patient is coming into their emergency department today. Not everything you learn needs to go into the note: what does go into the note should center on the patient’s presenting complaint including your subjective, objective, assessment and plans portions of the note. Said another way, everything included in your note should be PERTIENT to the patient’s complaint and your thinking about this complaint.
Almost all ED charts come in the form of template printed sheets (less common) or electronic health records ((EHR)- more common). These templates dictate much of the formatting and organization of the notes that you will be writing. Check boxes (i.e. review of systems) or auto-populated portions (i.e. family or past medical history) may help or hinder your ability to craft your ED note. Many EHRs use a SOAP note template to structure ED notes, but you should recognize that you will need to include more details than the typical SOAP note. In some EHRs the assessment/plan appears above the subjective and objective portions of the note; referred to as an “APSO” note. This reordering happens to highlight the importance of what you think is going on with the patient (i.e. your interpreting skills) and what you plan to do about it (i.e. your management skills) rather than your reporting skills of the subjective and objective portions of the note.
The Subjective Portion of the ED note
The subjective portion of your ED note contains two essential elements: the chief complaint and a history of present illness. Classically, the chief complaint is the main reason (which is very often a symptom such as pain) that the patient is seeking medical care and is captured in the patient’s own words. As examples, “I’m here to find out the cause of my knee pain,” or “I’m in need of a refill of medications,” would be typical chief complaints. The history of present illness (HPI) captures the details of the chief complaint. For completeness and accuracy, the HPI should be a chronological story of the chief complaint that identifies the seven attributes of a symptom: onset, location, quality, severity, timing/frequency, alleviating factors, and aggravating factors. An acronym, OPQRST, can be used to help remember to cover many of the attributes of a symptom (see fig 2). These can usually be captured in 1-2 carefully crafted sentences.
|P||Provoking and Palliating factors|
|Q||Quality of symptoms|
The subjective section of a SOAP note can also include factors you deem pertinent to why the patient is seeking medical care. This could be an interpretation of pertinent positive and negatives from the ROS, relevant past medical and surgical history or social risk factors, if you believe they are relevant to the reason for presentation. Documentation of over-the-counter and prescriptions medications, and any medication allergies, is essential to appropriate medical documentation in the ED.
When considering patients with more chronic problems, or an acute exacerbation of a chronic illness, there are some subtleties that you may wish to consider. You will want to quickly revisit the history of the chronic medical problem and confirm your understanding of the patient’s experience with the disease. Report compliance with any medications or medication side effects, any current symptoms or complications related to the chronic illness, any end organ affects from the chronic illness, and any health maintenance needs related to the chronic illness. Finally, any specific information related to the patient’s agenda for seeking medical care today, or personal situations that impact the patient’s ability to comply with care plans may be included in the subjective portion of the ED note.
The Objective Portion of the ED note
The objective section of ED notes is particularly dedicated to what we can observe or measure during our interaction with the patient. This portion must be written using standard medical language or commonly accepted abbreviations and should not include any quotes from the patient or common language to describe the physical examination. Standard features include vital signs, general appearance, the relevant physical examination, and any laboratory or imaging results. Maintaining this order of data is important because it is how your readers expect the information to be delivered. Adherence to this typical ED note template increases the efficacy of information transfer.
Recording your physical examination is vitally important and you should provide details of exactly what you performed during the encounter. When recording the physical exam you should NOT state the HEENT exam is “normal” or “WNL (within normal limits)”. Specifically state what you performed and wish to become part of the patient’s medical record. Use precise terms or commonly accepted abbreviations in writing out exactly what you did during the physical examination. Pictures can be very helpful for localization of pain, lesions, etc. Many EM physicians have a core set of physical examination maneuvers that they automatically perform on every patient even if it does not relate directly to the patient’s presenting complaint (fig 3). To some extent this happens for financial reasons, to achieve a certain billing level. It also highlights the need to perform a fairly extensive physical on all patients, in order to put isolated PE findings into context of the entire exam. In the objective portion of the SOAP note the adage that was mentioned previously, “if you didn’t document it, then you didn’t do it” certainly applies. To create a complete and accurate ED note, you will need to be thorough and conscientious with your physical examination documentation. If you order laboratory or radiologic studies during the visit, the results of these studies can be included at the end of the objective portion of the ED note. It should be noted whether the imaging interpretations are your reads, preliminary radiology reads, or final reads.
|Area of exam||Common “normal”||Examples of significant “abnormal”|
|CNS/psych||Alert, conversant, symmetric face and movement, no tremors, normal gait||Decreased LOC or agitation, lateralizing weakness, gait disturbances|
|Cardiovascular||Normal S1S1, equal pulses, warm pink skin||Murmurs, poor perfusion, abnormal heart rate, cool or pale skin|
|Pulmonary||Nonlabored, no distress, equal breath sounds||Labored, wheezes, crackles, asymmetric sounds|
|Abdomen||Flat, non-tender||Distended, tender|
|Extremities||No edema, no deformities, symmetric||Edema, deformities, asymmetries|
The Assessment Section of the ED Note
The assessment section of the ED note is one of the most important parts of the note as it displays your clinical reasoning about the patient’s presentation. You have now moved from the reporting or recording portion of the note, into the section where you will be documenting your medical decision-making about the patient. This is where the real “doctoring” begins. In the assessment section of the ED note, you are discussing what you think may be going on with the patient and why you think it. This is the essence of medical decision-making. For established or stable problems the medical decision-making may be very straightforward but for acute or complex problems the medical decision-making may be very nuanced. To keep the assessment portion of your ED note concise and organized it is helpful to break the assessment section into its component parts: the summary statement, the problem list, and the differential diagnosis discussion.
The summary statement is a written sentence or two that captures the patient’s agenda for seeking medical care using abstract descriptors, while highlighting a few of the most significant elements of the subjective and objective portions of the SOAP note. Traditionally, the summary statement would contain the patient’s demographic information (such as age and gender), and those pieces of information from the subjective and objective sections that help to inform you and the readers of your note what you think may be going on with the patient. It is NOT a repeat of the chief complaint. Rather, it is a concise summary that puts the chief complaint into context, while risk stratifying the patient for the reader (fig 4). This statement is often where the reader goes first, because it should both sum up what you have so far, and hint at where you’re going in the future. Often, the process of writing up your summary statement, problem list, and differential diagnosis helps to clarify your thinking about the patient and organize your thoughts about their presentation. Stop and put some thought into it.
|Chief complaint||Summary Statement|
|Mr Jones is a 65yo male who presents to the ED with 2 days of chest pain, and is “worried about having a heart attack”||Mr Jones is a 65yo African American gentleman with multiple cardiovascular risk factors who presents with 2 days of typical exertional cardiac-sounding chest pain|
|Ms Smith is here to “get checked because her belly hurts and she is worried about having an STD”||Ms Smith is a 23yo very uncomfortable appearing heathy sexually active female with 2 days of progressive abdominal pain concerning for ectopic pregnancy, PID, ovarian torsion, appendicitis or other acute abdominal pathology|
There are several ways to approach your medical decision-making in the assessment. The emergency medicine focused way of approaching your differential diagnosis highlights your thinking about the possibility of the serious, life or limb threatening conditions that could be present in your patient, as well as what you think is most likely going on with the them. One common analytical approach is to utilize a Prioritized Differential Diagnosis. For more information about developing your differential diagnosis see the CDEM chapter on clinical reasoning.
Prioritized Differential Diagnosis
- Tier 1 : The Most Likely or Probable Diagnosis
- Tier 2 : Serious or Can’t Miss Diagnoses
- Tier 3 : Less Likely or Less Probable Diagnoses
- Tier 4 : Interesting or Treatable Diagnoses
The next segment of the assessment is the problem list. While many ED visits will only require have one problem to be listed, it is not uncommon for an ED note to have several different entities under the problem list. Each will need to be detailed in this section. Many times these secondary problems have a direct impact on the first problem (example: hypertension and coagulopathy as secondary problems in a patient with an aortic dissection). These each need to be listed and discussed in the assessment and plan. Most often the problem captured by the patient’s chief complaint becomes the first problem listed, as it is likely the most pressing issue on the patient’s agenda. Other problems, if immediately relevant, are listed next on the problem list. Finally, any stable or chronic medical problems that may be relevant to the patient’s presentation are listed. You should normally have a brief discussion of a plausible differential diagnosis for each acute problem on your problem list. You may not need a differential diagnosis for known chronic or stable problems.
Parts of the Assessment Section of the ED Note
- Summary Statement
- Problem List
- Discussion of Differential Diagnosis
The Plan Section of the EM Note
The plan section of the EM note is where you describe the plan of action for the patient. Typically, three domains should be touched upon for each plan section: diagnostic recommendations, treatment options, and follow-up plans.
Diagnostic recommendations could be observation, laboratory tests, radiologic imaging, ECGs, or more sophisticated diagnostic procedures such a stress test. Treatments generally fall under medications and therapeutic procedures. Medication recommendations should detail the type of medication, dosing, frequency of administration, route, and length of treatment. Inpatient procedural recommendations almost always involve input from consulting services, and discussions with these providers should be detailed in the note. Outpatient recommendations, such as physical therapy, should mention plans for referral into these services.
Formatting the Assessment and Plan Section of the EM Note
The assessment and plan section of the EM note is often combined into one single section. Frequently, in an EHR, the assessment and plan is a completely open free text box. Multiple formats exist to template the assessment and plan, but a combined assessment and plan is recommended. For this type of formatting, there is an overall summary statement and problem list, but the plans for each problem are listed directly below the discussion of the differential diagnosis for each particular problem. Variations include side-by-side listing of assessment and plans and completely separate assessments and plans. The format with a combined assessment and plan that many prefer is noted below. Your particular emergency department will ultimately dictate the format and structure of your EM note, but you can expect to have the ability to formulate your own assessment and plan section. This is the most important part of the note, and requires practice to master.
Combined Assessment and Plans for the ED Note
- Assessment: Problem #1 – Differential Diagnosis Discussion and Plan:
- Assessment: Problem #2 – Differential Diagnosis Discussion and Plan (as needed)
- Assessment: Problem #3 – Differential Diagnosis Discussion and Plan (as needed)
Ultimately, you will need to decide on the disposition of your patient. The second most important question in emergency medicine (behind “sick or not sick?”) is: “Is this patient being admitted or discharged?” If you are admitting, you should detail the level of care recommended (such as the ICU, step-down unit, telemetry unit, regular floor, or brief observation unit) depending upon the patient’s condition, severity of illness and/or vital signs. If you are discharging the patient, you should always address follow-up plans with a primary care physician, a specialist, or back in the ED. This closes the loop, allowing assessment of the appropriateness and effectiveness of your diagnosis and treatments. We cannot overemphasize the importance of solid return precautions, with specific details related to the reasons why a patient should come back to the emergency department,. These must include details on specific symptoms, timing, severity and any other characteristics that should prompt return. Err on the side of caution. These return precautions must be discussed with the patient, and you should document that they are understood, agreed upon, and that the patient has the insight and support to return if needed. While not explicitly part of your EM note, the discharge paperwork and return precautions are definitely part of the patient’s medical record and something that you may be responsible for completing for your patient.
Essential Elements of Return Precautions
- What specific symptoms should cause concern?
- What is the severity of the symptoms that should prompt a return visit?
- What is the urgency or timing of returning to the emergency department?