Of all the components in an electronic emergency department information system (EDIS), the transition from documenting on paper to documenting using a computer is the most challenging one. Adequate preparation with strong executive support and accountability at the highest level are essential for success. Physician and/or nurse managers must be committed to “driving” the process from conception through implementation then onto continuous upgrading of clinical content, features, and functionality.
Ever since the beginning of medicine, the purpose of documentation has been to communicate a concise clinical summary of the patient evaluation. The ideal document is a brief, well-organized narrative that focuses on positive and pertinent negative signs and symptoms, clinically significant test results, and the medical decision-making thought process.1
The Changing Role of Documentation
The role of documentation changed in 1995 when Medicare published their evaluation and management (E/M) documentation guidelines for reimbursement.2 The guidelines specify the number of elements that must be documented in each part of a history and physical examination in order to receive compensation for patient E/M. Failure to include all elements results in less compensation. Submitting claims with extensive documentation to justify an inappropriately higher level of service constitutes fraud subject to possible penalties and fines. While the guidelines were initially intended for Medicare patients, they were subsequently embraced by commercial insurance companies as well.
In addition to documentation requirements for reimbursement, a rising rate of medical litigation in the United States has led to more extensive testing and expanded documentation based on a “not documented, not done” mentality.3
In order to meet the increasing demands for reimbursement and risk management, documentation templates evolved. While handwriting and dictation produce a document in the physician's own words with complete flexibility to accommodate any workflow, handwriting is time consuming and often not legible, while dictation is costly and is not available immediately.
Previously, paper templates were used in the majority of emergency departments (EDs). A collection of just 50 or so complaint-based paper templates allow a nurse or a physician to document a complete patient encounter by making marks on a single sheet of paper. Well-designed templates include prompts for reimbursement requirements, key data elements required for regulatory compliance, and reminders of high-risk considerations. Users report that making marks on a template is more efficient than writing or typing prose and is even faster than traditional dictation. Paper templates have been proven to improve reimbursement levels.4 The cost for paper templates is a fraction of that for dictation.
The Mandate for Electronic Documentation
Adoption of electronic documentation has been a much slower process. In April 2004, President George W. Bush made an executive order calling for widespread use of electronic health records (EHRs) for most Americans by 2014. The challenge was to ...