I know that documenting feels like the bane of our existence most of the time, but it is one of the most important things that we do, for a variety of reasons. The following pearl is going to go through aspects of documentation that I believe are important for residents to know.
Side note, I by no means am an expert in documentation, if anyone feels as though they would like to add some thoughts to what I describe below, please be my guest.
In my opinion, there are 4 main reasons that we document in the ED: Billing, Legal, Medical Providers and Patients.
Billing:
There could be an entire lecture series dedicated to the intricacies of billing within medicine, so for the sake of brevity, I am only going to touch on some basics.
Each ED visit is given a Level Of Service (LOS) which ranges from 1-5, the higher the LOS, the more that can be billed. The LOS is determined by the medical care required and interventions performed for each patient. Since January 1st, 2023 the LOS has been determined by the Medical Decision Making (MDM) section of our notes. There are many additional things that can be billed for a visit, but the LOS is the starting point.
For now, I’m not going to dive into what components of an MDM determine what LOS a patient gets billed for, but I will provide some examples of typical Patient encounters for each LOS.
LOS 1: Simple Telehealth Visit, Vitals check by a nurse – This LOS does not really exist for patients we see in the ED.
LOS 2: A single self-limited or minor problem, a Young healthy patient with a complaint of constipation, A jammed finger while playing basketball that does not require imaging
LOS 3: Typically a single, acute uncomplicated illness i.e. a young healthy patient with a URI or UTI.
LOS 4: A chronic illness w/ exacerbation or acute complicated injury. A distal radius fracture that requires splinting with ortho follow up, an I&D, shoulder reduction, asthma exacerbation in a young healthy patient who is ultimately discharged
LOS 5: The vast majority of patients we see, any patient that requires surgery, admission to the hospital, or at least consideration of an admission.
Legal:
Unfortunately, being involved in a malpractice lawsuit is something the majority of us will experience in our careers. More than 75% of ED physicians are named in a malpractice lawsuit at least once.
The most common errors in documentation that can lead to litigation are:
- Missing Documentation
- Inaccurate documentation
- Poor Mechanics: transcription errors, delays in documentation
From my research, the most important takeaways to protect yourself from medical litigation are:
- Document your communication with parents, family members, and consulting services thoroughly
- Provide thoughtful and accurate discharge instructions, follow and return precautions in a way that the patient is able to understand
- Avoid any chart inaccuracies as much as possible.
If you are interested in reading more regarding legal pitfalls of documentation, the article: “Charting practices to protect against malpractice: Case reviews and Learning Points.” By Ghaith, S. Et al. in the Western Journal of Emergency Medicine does a great review.
Medical Providers:
We see our patients for a brief moment in time before they are ultimately under the care of other medical providers who often know the patient better than we do. Our patients are not always able to fully comprehend what their problems are or what we do for them while in the ED.
It is incredibly important that we keep in mind future medical provides when writing notes for our patients. Their future inpatient providers, their primary care physician, physical therapists or home health aids may all refer to our documentation to make decision for the patient.
Patients:
Since the Cures Act was signed into law in 2016, patient’s are now able to view the notes that we write about them. It is more important than ever that when documenting we are factual, respectful and avoid negative descriptors for our patients.
