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Why Does Documentation Matter to the ED Leader?

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The emergency department (ED) leaders wear many hats: compliance officer, quality control specialist, risk and public relations representative, to name a few. Perhaps surprising to some is the role that documentation plays in many of the ED leader's crucial tasks. Documentation is critical to complying with the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) standards (including billing, coding, and accreditation); measuring ED quality of care; successfully defending malpractice claims; and resolving complaints from patients, family, and other providers. From this viewpoint, it is clear that excellent documentation is critical to the success of an ED, its staff, and its leaders.

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Chapter Outline

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This discussion of ED documentation touches on 4 main topics. This chapter

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  • Reviews the medical record itself, its evolution, and the most common documentation methods used in EDs today
  • Acknowledges today's regulatory standards for documentation and their relevance to successful ED operation
  • Provides an overview of control of the medical record
    • To whom the record belongs
    • To whom access may be granted
    • By whom and under what circumstances the record may be altered
    • The ever-broadening concept of health information confidentiality in the electronic age
  • Elucidates legal ramifications of the medical record—in whatever form the record takes—and common pitfalls to avoid in practice

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Key Learning Points

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  • Evolution of the medical record
    • History, evolution, and modern incarnation of documentation
  • Control of the medical record
    • The who, why, and how of record access and amendment
  • Legal ramifications and pitfalls of medical record-keeping
    • How to make the most of intelligent documentation

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Case 1

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An appropriate beginning is a familiar scene that illustrates the importance of excellent ED documentation:

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It is Monday morning and your office voicemail greets you with a complaint from a local family practitioner about the care rendered in your ED for one of his patients over the weekend. The practitioner is upset that a bio-occlusive narcotic patch was prescribed for his patient because this patient was, to his knowledge, opiate-naïve.

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First step: Review the record from the ED visit. As anticipated, the treating ED physician documented the standard components of a focused history and musculoskeletal physical examination for this patient presenting with acute-on-chronic localized joint pain. You are pleased that the medical decision-making section of the template has not been left blank. Instead, the treating ED physician documented her reasons for prescribing transdermal narcotics, including the patient's emphatic denial of pain relief with oral extra-strength hydrocodone (prescribed by a local orthopedist) and his repeated requests for inpatient admission for pain control and immediate arthroscopic surgery. Armed with this information, you place a call directly to the family practitioner (without first having to track down the ED provider to plumb the depths of her medical decision-making) and ...

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