Introduction
Whether rotating in the Emergency Department or elsewhere, one of the critical skills to learn is writing a complete and legible patient record. Documentation in the emergency department is usually challenging, and it may be difficult to adequately capture and note things promptly, especially when dealing with high acuity or critical case scenarios. Even as a medical student or intern, your medical record is essential. It reflects your general approach, thought process, care provided to patients, and potentially identifying gaps in your knowledge and training. Attending physicians, clerkship directors, and faculty usually emphasize and pay attention to how notes are written and may use them for summative or formative assessments and feedback. These documents are also crucial for communication between the emergency department and respective physicians, specialties, and other stakeholders. Appropriate medical documentation improves the quality of communication within an emergency department and aids the quality assurance process.
“It is said that if something is not written in the chart, it never happened.”
A well-organized and legible chart gives auditors and reviewers a clear picture of the physician’s thought processes and actions. It provides a real-time snapshot of a patient’s general condition at any given encounter. There is always room to learn about and improve medical documentation in the emergency department; therefore, this section will review the critical elements used in ED documentation [1,2].
Emergency Medicine Note
Before writing your note, nursing triage notes and vital signs, if available, need to be reviewed. If apparent discrepancies are seen, they need to be verified with the nurse and patient, as they may be errors. In addition, any abnormal vitals in triage must be acknowledged and written in the notes. Like any other medical record, the ED document comprises history, physical examination findings, differential diagnoses, ordered investigations, laboratory and imaging results, assessment, and plan. Each component will be discussed separately, and suitable examples will be provided accordingly [2-4].
History
When writing a patient’s history, one must be clear and thorough yet concise, avoiding lengthy and complex phrases. Ideally, the history should flow in a logical and chronological sequence. Unnecessary details are better avoided, as they serve as distractors and may confuse other readers. Recording the date and time the patient was seen is crucial, especially in critically ill patients. It will help create a timeline for when time-sensitive interventions or medications were administered [3,4].
The components of history
Chief Complaint
This usually includes the presenting complaint, ideally in the patient’s own words, with the duration (e.g., abdominal pain for two days).
History of Present Illness
Generally, there are two formats for writing the history of present illness (HPI): narrative and bullet points [5,6]. Both are acceptable as long as history is written comprehensively, concisely, and coherently. It is valuable to add pertinent negatives and positives when writing the HPI. It would show the physician’s thought process and lead the person reading the chart toward what differential diagnoses to consider and what to rule out depending on what the patient is presenting with. Specific mnemonics may aid in writing a systematic HPI (e.g., OLD CARS or OPQRST).
Example 1:
A 45-year-old man with a history of Coronary Artery Disease and Hypertension presented to the ED with chest pain that started three hours prior. The pain was gradual onset while sitting on his chair, localized in the center of the chest, and lasted for 20 min. It was described as “a heavy boulder on my chest.” It started when he quarreled with his daughter and was relieved with sublingual nitroglycerin. It was associated with nausea and sweating but not vomiting. It was localized and did not radiate into the shoulders or arms. He claimed the pain was moderately intense at 4/10 on the scale. The patient denied shortness of breath, palpitations, dizziness, or abdominal pain.
Example 2:
A 26-year-old male, previously healthy, presents with a sore throat for one week. It is associated with subjective fever and fatigue. It is aggravated whenever he drinks or eats, but he denies any difficulty swallowing or drooling. Also denies any chills, runny nose, cough, night sweats, or shortness of breath. No recent travel history was reported. Has several sick contacts at home with similar symptoms
Review of Systems
Other organ systems and symptoms not mentioned in the HPI must be reviewed to ensure that the patient has no other complaints or organ system involvement. If a review or system (ROS) cannot be obtained because of the patient’s underlying condition (i.e., unconscious, critically ill, or having dementia), this should be noted in the chart. Generally, patients are asked questions from head to toe (e.g., “Do you have a fever, chills, headache, sore throat, chest pain, abdominal pain, urinary symptoms, etc.”). Document all positive ROS symptoms and state the remaining symptoms as otherwise normal [7].
Past Medical/Surgical History, Medications, and Allergies
List any known illnesses that the patient might have had in the past. Include any surgical procedures he had. State what medications he is actively on and whether he has any drug or food allergies.
Family and Social History
Document a brief family history relevant to the chief complaint (e.g., family history of diabetes and cardiac disease in a patient presenting with chest pain). Social history mainly includes questions about smoking habits, alcohol consumption, sexual history, and illicit drug use. It might also be essential and relevant to ask about the patient’s financial and health insurance status, particularly in specific healthcare settings, to avoid ordering unnecessary tests and paying extra costs.
Physical Exam
Recording physical exam findings starts with the patient’s general appearance and vital signs, highlighting abnormal ones. It is important not to document or fabricate any findings that were not examined, as committing to such findings may have medical and medicolegal implications that are best avoided. Document all findings from the examined systems, including inspection, palpation, auscultation, etc. There is no need to document findings not pertinent to the chief complaint (e.g., neurological examination findings in a patient with a sore throat). Include important positive and negative findings for any given case [3].
Example:
A patient with abdominal pain
- Important positive findings: Soft, non-tender abdomen, normal active bowel sounds
- Important negative findings: No rebound tenderness, guarding, rigidity, or peritoneal signs
Assessment
It should capture the essence of the case and defend the rationale for further investigation. It usually includes an objective case summary, with differential diagnoses based on history and physical examination findings.
Plan
This section includes the investigations, medications, procedures, and consultations to be ordered or performed. The consultation time is crucial; the doctor’s name and recommendations must be promptly documented.
Disposition
This is usually the last part of the note. It indicates whether the patient will be admitted, discharged, or transferred to another facility. If discharged, follow-up and return instructions should be documented clearly [2-4].
Summary of all components in an ED Note
- Chief complaint
- History of present illness with pertinent positives and negatives
- A brief review of systems
- A focused past medical and surgical history
- Pertinent medications and allergies
- Family and social history, if relevant
- Vital signs, highlighting any abnormal readings
- A focused and appropriate physical exam
- Assessment with differential diagnoses
- Plan
- Disposition
Few helpful suggestions during documentation
- Place the date and time on all notes in the medical record.
- Write notes clearly and legibly.
- If you make a mistake, draw one line through it and sign your initials.
- Document a focused but thorough history and physical.
- Avoid using unclear abbreviations that are not commonly used.
- Document vital signs and address abnormalities.
- Document the results of all diagnostic tests that were ordered when appropriate.
- When speaking to a consulting service, document the physician’s name and the time the call was made.
- Document the patient’s response to therapy.
- Document repeat examinations
- Document your thought process (medical decision-making)
- Avoid writing derogatory comments in the medical record.
- Avoid changing or adding comments to medical records after completion. An addendum may be appropriate, but only if appropriately timed and dated.
- Document all procedures performed.
- If a patient leaves against medical advice (AMA), document that you have explained the specific risks of leaving and that the patient acknowledges and is aware of the risks.
- Document plan for outpatient care and follow-up
- If using an electronic medical record (EMR) instead of a handwritten one, all of the above sections, components, and suggestions apply [1,8,9].
Sample ED Note
Date & Time: 23/04/2022 at 07:40 AM
Arrival Mode: Private Vehicle
Source of History: Patient and Father
History Limitations: None
Chief Complaint
Abdominal Pain – since 6 hours
History of Present Illness
A 17-year-old male is brought to the ED complaining of abdominal pain since 6 hours of gradual onset. The pain started in the epigastric area and is now localized around the umbilicus. Pain is localized, persistent, and achy, without radiating to the back. It is associated with nausea and two episodes of vomiting. The vomiting is mostly food content and yellowish fluid, with no blood or bile noted. The patient was ill with nasal congestion and throat pain yesterday. He had a subjective fever at home and a decreased appetite. Denies chills, headache, yellowish eye or skin discoloration, diarrhea, or urinary symptoms. He denies eating food from outside in the past two days. No recent travel or sick contacts were reported. Did not try any medications or remedies at home.
Review of Systems
Other than HPI, the review of systems is otherwise normal.
Past Medical History
Unremarkable
Medications and Allergies
No known allergies and not on any regular medications
Family History
Both parents are known to have Hypertension only.
Social History
Denies alcohol consumption or illicit drug use.
Physical Exam
- The patient appears to be in moderate pain, holding his abdomen.
- Vitals: BP 130/80 mmHg, PR 120 b/min, RR 20 breaths/min, O2 Saturation: 94% on room air
- Head and Neck: Dry oral mucosal, no cervical lymphadenopathy
- CVS: Symmetrical pulses bilaterally, S1, S2 heard, no murmurs
- Lungs: Clear to auscultation bilateral with no crepitations or wheezes
- Abdomen:
- Scaphoid abdomen and not distended on inspection,
- tenderness palpable in the epigastrium, umbilical area, and right lower quadrant
- Positive rebound tenderness in the right lower quadrant
- Positive Rovsing’s and Obturator signs
- No palpable masses or hernias
- Negative Murphy’s sign
- Auscultation revealed sluggish bowel sounds
- Rectal exam revealed a normal tone with no blood in the glove
- Genital Exam:
- Normal genitalia with no swelling, hernias, or tenderness
- Normal lying testes with no evidence of torsion
- Normal cremasteric reflex on both sides
Assessment
A 17-year-old previously healthy male presented to the ED with a 6-hour history of abdominal pain of gradual onset associated with anorexia, subjective fever, nausea, and vomiting. The physical examination revealed stable vitals, with abdominal examination showing tenderness in the epigastrium and right lower quadrant with rebound tenderness and positive Rovsing’s and obturator signs.
Provisional Diagnosis
Acute Appendicitis
Differential Diagnoses
- Acute Gastroenteritis
- Food Poisoning
- Diabetic Ketoacidosis
- Irritable Bowel Disease
Plan
- Medications / Treatment:
- 1 Liter IV Normal Saline
- 1g IV Paracetamol for pain
- 10mg IV Metoclopramide for nausea and vomiting
- Lab investigations:
- CBC w/Differential count
- Urea & Electrolytes
- Random Serum Glucose
- C-Reactive Protein
- Coagulation Profile
- Type and Screen
- Urine Analysis
- Imaging Studies:
- Ultrasound Abdomen
- Possible CT Abdomen in case Ultrasound is inconclusive.
- Consultations:
- General Surgery
Author
Muneer Abdulla Al Marzooqi
Dr. Muneer is a Consultant Emergency Medicine Physician from the UAE. He completed his EM residency at Tawam Hospital in 2017 and has served as an attending physician and educator there since. He is the Program Director of the Emergency Medicine Residency Program at Tawam Hospital, focusing on medical education, peer development, EM Resuscitation, Simulation, and POCUS. Dr. Muneer has organized and lectured at various seminars and workshops in the MENA region for medical students, residents, and healthcare professionals, including Basic Ultrasound, POCUS, Airway, Suturing, ENT Emergencies Workshops, and the Chief Resident Leadership Program.
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References
- Murphy BJ. Principles of good medical record documentation. Journal of Medical Practice Management. 2001;258-260.
- Clerkship Directors in Emergency Medicine (CDEM), Society for Academic Emergency Medicine (SAEM). Medical Student Educators’ Handbook / edited by Robert L. Rogers and Mark Moayedi. 2010.
- Carrol S. Documentation | EM Basic [Internet]. Embasic.org. 2016 [cited 25 May 2016]. Available from: http://embasic.org/how-to-give-a-good-ed-patient-presentation/
- Carrol S. How to give a good ED patient presentation | EM Basic [Internet]. Embasic.org. 2016 [cited 25 May 2016]. Available from: http://embasic.org/how-to-give-a-good-ed-patient-presentation/
- Ronald, Schleifer., Jerry, B., Vannatta. (2011). 4. The Chief Concern of Medicine: Narrative, Phronesis, and the History of Present Illness. doi: 10.1215/00166928-1407531
- Adam, Kilian., Laura, A., Upton., John, N, Sheagren. (2020). 2. Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness. doi: 10.1177/2382120520928996
- Rui, Zeng. “4. Complete Physical Examination.” (2020). doi: 10.1007/978-981-13-7677-1_50
- 8. 5 Ways to Improve Medical Documentation in your Emergency Department – Bill Dunbar and Associates [Internet]. Bill Dunbar and Associates. 2014 [cited 25 May 2016]. Available from: http://www.billdunbar.com/2014/02/28/5-ways-to-improve-medical-documentation-in-your-emergency-department/
- The Art of Writing Patient Record Notes. Virtual Mentor. American Medical Association Journal of Ethics. 2011;13(7):482-484.
Reviewed and Edited By
Jonathan Liow
Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.
James Kwan
James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
