Emergency department (ED) documentation is the sole record of a patient’s ED visit, aside from the clinician’s and patient’s memory. Emergency physicians and advanced practice clinicians (APCs) are expected to be thorough, accurate, detailed, as well as efficient as they capture all patient information. Hospitals and other healthcare providers rely heavily on the accuracy of a patient record to perform essential job duties. Because of this hospital administration and clinicians must place a heavy emphasis on the processes to complete a patient account.
A clinical team’s focus on completing chart documentation requirements away from patient care may interrupt the natural flow of treating patients. Thorough and accurate ED documentation can place a tremendous amount of pressure on the clinical team and relieving this pressure does not come from quick fixes or workarounds.
Physicians and APCs should use a defined process with meaningful steps to complete ED visit documentation in a satisfactory way every time, maximizing appropriate information in the medical chart and minimizing negative effect on patient flow. Hospitals interested in improving documentation must start with identifying the current ED documentation process and make targeted improvement for each step. This process can reduce errors, prevent mistakes, and possibly lower the risk of readmission, billing issues or even malpractice lawsuits. When implemented properly, the improved process can actually make the emergency clinician’s job easier as well.
To identify areas of potential improvement, apply the following five resolutions to common ED documentation issues identified by ApolloMD, emergency medicine physician services experts.
Emphasize the Importance of Documentation for Patient Care, Billing, and Malpractice Liability
The biggest challenge to thorough, accurate documentation is clinicians constantly asking themselves: “Why am I doing this?” If physicians and APCs do not understand the importance of certain documentation processes, then critical elements are more likely to be overlooked in the rush to get to the next patient.
Generally speaking, documentation serves a number of important functions, including:
- Patient Care — Communicating with other physicians, APCs and healthcare providers who might see the patient later and will need complete and accurate information to offer the best care
- Billing — Revealing the extent and complexity of actions taken during the emergency room visit, which will, in turn, justify the level of billing applied
- Liability Defense — Providing a record of actions taken to reveal adherence to a high standard of care that would make proving malpractice difficult
Clinicians must understand the importance of every single patient file to the organization’s as well as their own success. Once clinicians understand the gravity of the decisions they make when capturing documentation, they can self-correct practices which are more likely to lead to adverse outcomes.
Show All Work — Reveal Medical Decision-Making Process and Differential Diagnosis Considerations
It is easy for clinicians to gloss over the medical decision-making (MDM) component of documentation during routine ED visits. However, this section is integral to all three functions of documentation previously mentioned:
- Patient Care — Physicians and APCs who provide care for the patient in the future can see the logic applied to care decisions and whether the ED physician or APC weighed all possible differential diagnostic considerations
- Billing — More complex decisions can relate to higher levels of coding, especially for visits involving test results, multiple data sources or potential high-risk outcomes
- Liability Defense — MDM explanations can concretely reveal the standard of care applied by ED physicians and APCs and whether the clinicians followed professional standards
Mentioning all aspects of MDM can be time-consuming, but with an established process in place documentation should be by-the-numbers. Voice dictation, text macros, and scribe utilization are all used to help lessen the burden of this documentation.
The clinician should list all possible differential diagnoses which could present the symptoms described in the patient complaint. Begin with the most common diagnosis followed by the most severe diagnosis. The clinician should always consider the possibility of missing a “silent killer” diagnosis, such as a pulmonary embolism, ectopic pregnancy, pericarditis, pneumothorax, aneurysm thoracic dissection or acute coronary syndrome.
When a physician or APC shows he or she either ruled out or took appropriate steps to follow up on such conditions or possible high-risk scenarios, the likeliness of encountering an unexpected adverse event decreases.
Consider Altering Electronic Health Record (EHR) Templates for Different Patient Cases
Many documentation errors, mistakes and issues stem from the use of template-based software. While templates save time, they can pigeonhole clinicians into describing an inaccurate narrative if the option to amend the template is not available.
Clinicians should watch out for generic responses that lead to inaccuracies and, later on, potential evidence of negligence. More outlandish examples include an unresponsive patient who “denies chest pain” or recording “bilateral” radiating ankle pain in someone with an amputated leg.
Apply Strict Standards for When Medical Records Can Be Accessed, Modified or Amended
Every EHR stores metadata to show when the file was retrieved or modified. Patient privacy laws demand patient records to be accessed only at necessary times by appropriate personnel. All modifications should either correlate to a new patient visit, addition of documentation originally missed by the clinician, or the correction of erroneous information previously captured. If a record is amended, the physician or accessing team member should provide justification for why the record was changed.
Suspicious access, especially editing of EHRs may allow an insurer to deny coverage, or worse, such access can be evidence of fraud.
Conversely, physicians and APCs should consider whether there is an absence of accessing a record during times of a supposed patient visit. If, for instance, a physician claimed to be in attendance during a lengthy procedure but did not document vital signs for hours at a time, his or her statements might be viewed with suspicion.
Similarly, edits or amendments made to a record several days after a patient visit raises a red flag and has the potential to lead to inaccurate EHR statements. Clinicians should always document the patient visit as soon as possible while the information is still fresh and most likely to be an accurate account of the visit.
“Close the Loop” Before Discharging, Referring, or Admitting Patients
Physicians and APCs should transition patients to either a different level of recommended care or discharged with proper instructions to know when, or if, the individual should return to seek care.
For patients being admitted, documentation should note the level of care recommended given the patient’s condition — such as ICU vs. brief observation unit, etc.
For discharged patients, instructions should include clear written and verbal instructions explaining next steps, self-care, follow-up and, most importantly, what circumstances should prompt the individual to return to the ED immediately.
Providing instructions to patients and the future clinician team in this way “closes the loop,” leaving everyone with an idea of the specific duties expected in order to prevent a possible adverse event from happening.
Discharge instructions are particularly important when a patient chooses to leave without treatment (LWOT) or against medical advice (AMA). LWOT patients are more likely to be readmitted and have a higher risk for 90-day mortality. For AMA patients, physicians and APCs must be able to prove the patient opted for an “informed refusal of care” which demonstrates the patient understands the possible consequences and associated risks of his or her decision.
Solve Problems Before They Start
Clinicians have numerous opportunities to improve emergency documentation by:
By taking these steps to improve documentation and remain efficient, physicians and APCs will benefit their patients, their hospital, as well as themselves.
