How to Improve the Emergency Department’s Documentation Process

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.

For example, the clinician should consider commenting on pulmonary embolism in a patient with chest pain or shortness of breath. John Bielinski of the Emergency Medicine Institute believes, “pulmonary embolism is the grim reaper of chest pain and shortness of breath. It is incredibly sneaky. You have to rule out PE and acute coronary syndrome. This is especially true for newer emergency medicine practitioners because you can easily be blinded by a bias to benign.”

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.