By the end of this module, the student will be able to:
Understand the utility of written documentation as it relates to the practice of emergency medicine.
Be able to document an emergency department (ED) patient encounter using the SOAP note organization/format.
Recognize the importance of describing medical decision making in the assessment and plan section of ED documentation.
Introduction to Medical Documentation
Why do I have to write EVERYTHING down? Why can’t I just take care of my patients? All this documenting is preventing me from doing my job!
These statements reflect the frustration that many physicians feel regarding how much time completing written medical documentation can take. Balancing the time demands of patient care and charting can be difficult. In this chapter, we explain the purpose and structure of the ED note in order to help you build the skills needed to effectively document your patient encounters and medical decision making in the ED medical record.
Purposes of the Emergency Department Note
Why is written documentation so important? The ED note serves multiple purposes:
- Communication– Rarely is an ED encounter so self-limited that no one else needs to know about it. Our chart is the main way we communicate with other health care clinicians (and even with patients) about what happened in the ED (e.g., diagnostics, treatments, our thought processes, discussions with patients and families about their concerns and desires, discussions with consultants about their recommendations and patient care plans).
- Billing– Medical documentation serves as the primary tool for coding and billing for patient care services provided in the ED.
- Medicolegal Protection– The medical record is a log of the events and thought processes that occurred during the ED visit. In the event of a poor clinical outcome, patient complaint, or lawsuit, the chart is the final (often the only) representation of what happened during the patient encounter. The adage of “if it wasn’t written down, it didn’t happen” has haunted many a competent and well-meaning physician. The ED record must be able to serve as our defense in these situations.
- Quality Improvement Reviews– Chart review is one of the main ways that health systems use to improve future patient care. Details that may not seem important to you (or your patient or consultant) might be very important to reviewers interested in quality or process improvement.
- Research– Retrospective chart reviews are often the starting point when asking a clinical research question. Clear documentation helps investigators gather data to devise future studies to improve patient care.
- Utilization Management/Risk Management– The hospital administrators review medical records to establish timelines and points of delay. Your charting (e.g., time documentation) can give them the tools they need to fix these delays.
Differences between ED notes and clinic or inpatient notes
Charting is important for all medical encounters. That being said, there are some specific differences between ED notes and notes by other clinicians.
Time Pressures- Clinicians in the ED are often under tighter time constraints than those in other care areas, resulting in limited time for documentation and placing a premium on efficient charting (a compromise between brevity and thoroughness: including everything you need to know, but nothing that you don’t). The hectic environment in the ED makes it difficult to remember exactly what happened and when, so timely completion of charting is critical for accuracy. Ideally, documentation should be complete at the time of final disposition.
A Note Must Stand Alone- Each ED note is an independent document as opposed to the chapter-like inpatient progress note or clinic note. In ED documentation, we reflect on information gathered from the patient encounter and diagnostics, how we dealt with the emergent issue at hand, any changes in clinical status, and plans for future care (such as hospital admission or outpatient follow up).
- Billing Mechanics- ED visits are billed differently than most other encounters. Our charts are graded on a complexity level from 1-5 based on the description of our medical decision making (e.g., complexity of problems addressed and of data review). If our medical decision making isn’t clearly documented, the chart gets significantly down-coded. Emergency physicians (EPs) can also bill for procedures they perform, and these must be recorded appropriately.
Different Goals of EPs vs Admitting or Clinic Clinicians- As opposed to comprehensive care, the ED role is assessment, stabilization, and appropriate disposition. We must have a “worst-first” approach to the differential diagnosis (DDx), rather than always identifying a single, definitive diagnosis. Charting needs to reflect which problems are being addressed during the ED encounter as well as our clinical reasoning regarding each one. Explaining your thought processes about the patient’s care is one of the most important goals of ED notes.
Medical Scribes- Because of the time pressures involved in evaluating and treating patients and keeping up with documentation, medical scribes are becoming increasingly common in EDs. Scribes must also understand the differences between documentation in the ED versus other parts of the health system. Scribe charting must be reviewed carefully since you are ultimately responsible for what scribes document.
Keep these purposes and differences in mind (Figure 1) as you complete your charting. Put yourself in the shoes of the people who will read your note. Remember things that frustrate you when you read other clinicians’ documentation and learn from their mistakes. Focused practice is needed in order to improve the clarity and efficiency of your documentation.
Qualities of an Emergency Department Note
The ED note should paint a picture of the patient encounter: how it began, how and why it evolved, how it came to a conclusion, and where it needed to go from there. It should tell a story that the reader can easily follow. Qualities that are essential to maintaining high quality medical records include completeness and accuracy in addition to conciseness and organization.
Completeness and Accuracy- A medical note must convey the pertinent details of the patient encounter and subsequent plan of care without including superfluous information. The paradox is that we often don’t know what will turn out to be important until later in the patient’s ED stay. For less experienced students, all information can seem potentially relevant to a patient’s presenting complaint(s) (and in fact it may turn out to be so!). Be patient with yourself -with more and more clinical experience, you will quickly gain a better understanding of what is most relevant or pertinent to include in your written documentation.
- Conciseness and Organization – As you start out in the ED, focus first on being accurate and complete, then strive to be concise. By effectively organizing your note, you will achieve conciseness by avoiding duplication and be able to meet the expectations of other health professionals reading your notes. In EM, the emphasis is on capturing the relevant details of the patient’s presentation that drive your DDx as well as describing your medical decision making. The question “Does this patient have a serious, life or limb-threatening condition?” is always on the mind of the EP, and your answer must be reflected in your medical documentation. Both the type of information that you select to include in your note and how you choose to organize it help accomplish this task.
Structure of the Emergency Department Note
The ED note incorporates components of a comprehensive H&P, a focused SOAP note, and a discharge summary. The challenge is including sufficient information to support your DDx, diagnostic/treatment plans, and conclusions while still keeping the note concise and quickly readable. Since most patients in the ED are initially unfamiliar with undifferentiated complaints, you must gather a fairly comprehensive H&P before building an appropriate DDx and treatment plan. Although EPs are interested in why the patient is in the ED today, peripheral information may be very relevant. Not everything you learn from the patient will go into your note. Everything that gets included in your note should be PERTINENT: focus on the patient’s presenting complaint(s) and the problem(s) that needed to be addressed.
ED notes generally follow a templated structure, which dictates much of the formatting and organization of your documentation. The first section is your summation of the patient’s history. Auto-populated portions (e.g., meds, family history, past medical history(PMHx)) can be helpful, but be careful because you are ultimately responsible for the accuracy of these sections. “Checkbox” sections (e.g., review of systems (ROS), physical exam) speed documentation, but be sure to only document what you actually asked about/parts of the exam that you actually performed. Avoid the temptation to click every box and remember to double check that you clicked the appropriate boxes (e.g., to avoid accidentally marking the “normal” box when there were actually abnormal findings). There is a section to capture the “ED course” and your “medical decision making.” These areas are used to chronicle how your patient responds to any treatments, if their clinical status changes, what your initial clinical impression is, how subsequent results influence your initial impression, and your plan for final disposition. If the patient stays in the ED past the end of your shift, sign-out notes may need to reflect the transitions of care between ED clinicians.
In some notes, the assessment/plan appears before the subjective and objective portions of the note (an “APSO” note). This reordering highlights the importance of what you think is going on with the patient (i.e. your interpreting skills) and what you plan to do about it (i.e. your management skills) rather than your reporting skills of the history and exam findings and results of diagnostics.
The Subjective Section of the Emergency Department Note
The subjective section contains two essential elements: the chief complaint and a history of present illness. Classically, the chief complaint (CC) is the main reason (often a symptom such as pain) that the patient is seeking medical care and is often captured in the patient’s own words (e.g., “I’m here to find out the cause of my knee pain.” “I need of a refill of medications.” “My wife thinks this chest pain needs to be checked out.”). The history of present illness (HPI) accurately and completely captures the details of the chief complaint. The HPI should be a chronological story that identifies the cardinal attributes of a symptom/problem: onset, location, quality, severity, timing/frequency, alleviating factors, and aggravating factors. Acronyms such as OPQRST (Figure 2) or OLD CARTS, help make sure you catch all the key points. Often this distills down to 3-4 carefully crafted sentences.
Example: Patient says his wife is worried he “has got appendicitis.” Pain began 2 days ago with mild vague intensity and nausea (no vomiting) and didn’t get better with his usual Maalox. This morning the pain moved to RLQ and was so bad that he couldn’t roll over in bed, and EMS was called.
The subjective narrative may also include ROS, PMHx, and other information you deem pertinent to addressing the presenting complaint.
Example: CC = Chest pain
62yo obese diabetic man presents with chest pain reminiscent of his previous heart attack
Previously healthy 32yo competitive tennis player presents with sharp chest pain when reaching up for a serve, but no other associated symptoms
Documentation of current medications (prescribed and over the counter) and any medication allergies is essential to appropriate medical documentation in the ED as well as safe patient care. The social context in which a patient seeks care can also affect their care plan and final disposition.
Example: CC = abdominal pain
45yo homeless alcoholic with gout presents for abdominal pain. He is out of all prescribed meds and has been using Advil to control his gout pain.
[Advil increases risk of ulcers, GI bleeds and perforation. Homelessness and alcoholism affect patient’s ability to follow-up.]
When considering patients with chronic problems or an acute exacerbation of a chronic illness, there are some subtleties that you should consider. Quickly revisit the history of the chronic medical problem and confirm your understanding of the patient’s prior experiences with the disease. Report compliance with any medications or medication side effects, any current symptoms or complications related to the chronic illness, any end organ effects from the chronic illness, and any health maintenance needs related to the chronic illness. Finally, any specific information related to the patient’s reason for seeking medical care today or factors that impact the patient’s ability to interact with the health care system and follow through with care plans should be included in the subjective portion of the ED note.
55yo man with well-controlled COPD presents for worsening wheezing exacerbation. Says he’s never been intubated and rarely hospitalized, but is visiting family from out of town and lost all of his meds and nebulizer in “lost-luggage-debacle.”
[You may need to refill all medications for the duration of his trip, and you know he won’t be able to follow up readily until he returns home]
The Objective Section of the Emergency Department Note
The objective section is dedicated to what we can observe or measure during our interaction with the patient. Write this section using standard medical language (or commonly accepted abbreviations) and don’t include any quotes from the patient to describe the physical examination. Always include vital signs, general appearance, the relevant physical examination, and any laboratory or imaging results. Maintaining this order is important because your readers expect the information to be delivered in this way, increasing the efficacy of information transfer.
For both medical and legal reasons, you should provide details of exactly (and only) what you examined during the encounter. Avoid general terms like “normal” (which implies a completely normal exam) or “WNL” (you may mean “within normal limits” but lawyers can turn it into “we never looked”). Specifically state what you checked, saw, heard, palpated in order to incorporate this information into the patient’s medical record. If you are able to do so, including pictures in your charting is very helpful for documentation of skin lesions, soft tissue injuries, etc. Many EPs have a core set of exam maneuvers that they automatically perform on every patient even if it does not relate directly to the patient’s presenting complaint.
Appears awake, alert, conversant and not in acute distress.
Pulm: unlabored equal breathing without wheezes or rales
CV: Clear S1S2 without murmurs. Equal brisk pulses and cap refill, no edema.
Abd: Soft with normal bowels sounds. No tenderness, guarding, masses or bruits appreciated.
This highlights the need to perform a fairly complete physical exam on all patients in order to put abnormal physical examination findings into context. “If you didn’t document it, then you didn’t do it” certainly applies, but so does “if you document it, you better have done it.” Create a complete and accurate note by being thorough and conscientious with your exam documentation. If you order labs, EKGs, or radiologic studies, include the results/interpretations at the end of the objective portion or in the ED course once they are available. Note whether interpretations are your independent reads, preliminary radiology interpretations, or final radiology reports.
The Assessment/Plan Section of the Emergency Department Note
This section is arguably the most important part as it displays your clinical reasoning about the case. Here you move from recorder/reporter to manager, and the real “doctoring” begins. Medical decision making (MDM) means discussing what you think may be going on with the patient, why you think it, and what you’re doing about it. Sometimes this is very straightforward (e.g., simple, superficial laceration), but it can be very complex in other cases (e.g., suspected pulmonary embolism in a patient with a recent head bleed). To keep the assessment portion of your ED note concise and organized, it is helpful to break the assessment section into its component parts: the summary statement, the problem list, and the discussion of the DDx.
The summary statement is 1-2 sentences that capture the reason the patient came to the ED and highlights important elements from the subjective and objective portions of the note. It is NOT just a repetition of the chief complaint and the patient identifiers. Rather it is a concise summary that puts the chief complaint into context while also risk stratifying the patient (Figure 3). This statement is often where the reader looks first because it should both sum up what you have done so far and hint at where you’re going in the future. Often, the process of writing up your summary statement, problem list, and DDx helps to clarify your thinking about the patient and organize your thoughts about their clinical presentation. Stop and put some thought into this statement.
The problem list is just that. For some patients, this list may include only 1 item, but it is not uncommon for an ED note to have several different problems listed. Often secondary problems have a direct impact on the initial one (e.g., hypertension and coagulopathy in a patient with an aortic dissection). Each active problem needs to be listed and discussed in the assessment and plan. Often the first problem listed is the chief complaint (or its direct cause). Other problems, if immediately relevant, are listed next on the problem list. Finally, any stable or chronic medical problems that may be relevant to the patient’s presentation and that are addressed during this visit are listed.
Each acute problem in your problem list needs a DDx, an explanation, and/or an indication of its relevance. Utilizing a prioritized DDx (Figure 4) reflects how EPs prioritize the worst and most likely conditions in their differential. You should include a brief discussion of the conditions that you are considering as part of the DDx along with reasons why you think these conditions should be considered or ruled out as part of the medical encounter. This section is typically wrapped up with a “Plan.” which often straddles the prioritized differential and the disposition section (see below).
- Aortic dissection: most likely DDx based on character of pain and new wide mediastinum. CT pending. Controlling blood pressure, heart rate, and pain.
- Consider pulmonary embolism, acute coronary syndrome, other causes (tests pending, aspirin held till CT)
- Will admit ICU (surgical if dissection, medical if CT neg)
- Reverse with FFP/PCC
- Rate controlled on esmolol
- Discussed with cards regarding anticoagulation reversal
- Hypertensive emergency- dissection vs ACS vs other
- Controlled now on esmolol
- Will need good oral control
- Currently stable
Chronic low back pain
- Avoid NSAIDs (antiplatelet risk)
Disposition for the Emergency Department Note
Ultimately you will need to decide on the final disposition for your patient. Your assessment and plan section should allude to their ultimate disposition. The second most important question in emergency medicine (behind “sick or not sick?”) is “Is this patient being admitted or discharged?” If you are admitting, you should detail the level of care recommended (such as the ICU, step-down unit, telemetry unit, regular floor, or brief observation unit) depending upon the patient’s condition, severity of illness, and/or vital signs. If you are discharging the patient, you should always address follow-up plans with a primary care physician, a specialist, or back in the ED. This closes the loop, allowing assessment of the appropriateness and effectiveness of your diagnosis and treatments.
Although not always integrated into the ED note, return precautions are a vital part of the medical record. The importance of return precautions (outlining specific reasons why a patient should come back to the ED) cannot be overemphasized. Return precautions must include details on specific symptoms, timing, severity, and any other characteristics that should prompt re-evaluation in the ED (Figure 5). It is best to err on the side of caution with these precautions. Discuss them with the patient. Document that they are understood and agreed upon and that the patient has the insight and support to return to the ED if needed. While not explicitly part of your ED note, the discharge paperwork and return precautions are definitely part of the patient’s medical record. As such, you are responsible for making sure these are done correctly.
Final Thoughts about the Emergency Department Note
Medical documentation is an integral part of the practice of emergency medicine. Understanding the purposes and uses of the ED note will help to shape the way in which your notes are written and organized. While ED documentation
follows a common structure, EPs can tailor their notes based on personal preferences and the expectations of the specific ED is which they work. Certainly the ED note must detail the pertinent information gathered from the patient
and provide a record of the patient’s care during their stay in the ED; however, the most important purpose of the ED note is to capture the emergency physician’s medical decision making.
Pearls and Pitfalls
The ED note serves multiple purposes: communication, billing, medicolegal protection, quality improvement reviews, research, and utilization management/risk management.
The emphasis is on capturing the relevant details of the patient’s presentation that drive your DDx as well as describing your medical decision making.
Auto-populated portions and “checkbox” sections of the chart can speed documentation, but be sure to only document what you actually asked about/parts of the exam that you actually performed. Avoid the temptation to click every box and remember to double check that you clicked the appropriate boxes.
The assessment/plan section is arguably the most important part as it displays your clinical reasoning about the case (what you think may be going on with the patient, why you think it, and what you’re doing about it).
For discharged patients, return precautions are vitally important and must include details on specific symptoms, timing, severity, and any other characteristics that should prompt re-evaluation in the ED.