by Muneer Al Marzouqi and Qais Abuagla
Whether you are rotating in the Emergency Department (ED) or elsewhere, one of the key skills to learn is how to write a complete and legible patient record. Documentation in the ED is usually challenging, as it may be difficult to adequately capture and note details down in a timely manner. This happens especially when dealing with high acuity or critical case scenarios. Even as a medical student or intern, your medical record is important on so many levels. It serves to reflect your general approach, thought process, the care you provided to patients, as well as potentially identifying gaps in your knowledge and training. Attendings, clerkship directors, and faculty usually emphasize and pay attention to how notes are written and may use them for summative or formative assessments as well as a means for feedback. These documents are also an important tool for communication between the ED and respective physicians, specialties and other stakeholders. Appropriate medical documentation improves the quality of communication within an ED and aids in the quality assurance process.
It is said that “if something was not written in the chart, then it never happened.”
Having a well-organized and legible chart gives the auditors and reviewers a clear picture of the physician’s thought process, the actions he/she performed, and provides a real-time snapshot of the patient’s general condition at any given encounter. There is always room to learn about and improve medical documentation. Therefore, this section will review the key elements used when documenting in the ED (Murphy, 2001; CDEM, 2010)
Emergency Medicine Note
Before writing your note, the nursing triage notes and vital signs, if available, need to be reviewed. If obvious discrepancies are seen, these need to be verified with the nurse and patient, as there may be errors. In addition, any abnormal vitals in triage must be acknowledged and written in the note.
Like any other medical record, the ED document will comprise of the patient’s history, physical exam findings, differential diagnoses, investigations ordered, lab and imaging findings, assessment and plan. Each component will be discussed separately, and suitable examples will be provided accordingly (CDEM, 2010; Carrol, 2016a and 2016b).
When writing the patient’s history, one needs to be clear, thorough, and concise avoiding any long and complex phrases. Ideally, it needs to 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 when the patient was seen is crucial, especially in critical patients, as it helps create a timeline for when time-sensitive interventions were done or when medications were administered (Carrol, 2016a and 2016b).
Components of the history include
1. Chief Complaint
This usually includes the presenting complaint, ideally in the patient’s words, with the duration (Example: Abdominal Pain – for two days).
2. History of Present Illness
In general, there are two formats when writing a history of present illness (HPI), the narrative format and bullet points format. Both are acceptable as long as the history is written in a comprehensive, concise and coherent manner. It is of added value if pertinent negatives and positives are added when writing the HPI, to show the physician’s thought process. This will lead the person reading the chart towards what differential diagnoses to consider and what to rule out, depending on what the patient is presenting with. Certain mnemonics may be used to aid in writing a systematic HPI (Example: OLDCARS or OPQRST).
Example 1: A 45-year-old man, with a history of Coronary Artery Disease and Hypertension, presenting to the ED with chest pain that started 3 hours ago. The pain was of gradual onset while sitting on his chair, localized in the center of the chest and lasted for 20 minutes. It was described as “a heavy boulder on my chest.” The pain started when he had a quarrel with his daughter and was relieved with sublingual nitroglycerin. It was associated with nausea and sweating, but no vomiting. Was localized and not radiating to the shoulders or arms. He claims it was moderately intense at 4/10 on the pain scale. He denies any 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 denies any difficulty swallowing or drooling. The patient also denies any chills, runny nose, cough, night sweats, or shortness of breath. No recent travel history reported. Has several sick contacts at home with similar symptoms.
3. Review of Systems
Other organ systems and symptoms that were not mentioned in the HPI are to be reviewed to make sure the patient does not have other complaints or organ system involvement. If the 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, ask patients questions from head to toe (Example: “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 ones as otherwise normal.
4. Past Medical/Surgical History, Medications, and Allergies
List any known active illnesses the patient might have or 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.
5. Family and Social History
Document a brief family history that may be relevant to the chief complaint (Example: Family history of Diabetes and Cardiac Disease in a patient presenting with chest pain). Social history mainly includes asking about smoking habits, alcohol consumption, sexual history and illicit drug use. It also might be important and relevant to ask about the patient’s financial and health insurance status, particularly in certain healthcare settings, to avoid ordering unnecessary tests and paying extra costs.
When recording physical examination (PE) findings start 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; committing to such findings may have medical and medico-legal implications that are best avoided. Document all findings from examined systems including findings from inspection, palpation, auscultation, etc. There is no need to document findings that are not pertinent to the chief complaint (Example: Neurological examination findings in a patient with a sore throat). Include important positive and negative findings for any given case (Carrol, 2016a).
Example: 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
Should capture the essence of the case and defend the rationale for potential further investigations. It usually includes an objective summary of the case with differential diagnoses based on history and physical examination findings.
This section includes what investigations, medications, procedures, and consultations are to be ordered or performed. Time of consultation is very important, and the doctor’s name and his/her recommendations are to be documented in a timely manner.
This usually is the last part of the note. It mentions whether the patient is going to be admitted, discharged, or transferred to another facility. If discharged, follow-up instructions and return instructions should be documented clearly (CDEM, 2010; Carrol, 2016a and 2016b).
Summary of all components in an ED Note:
- Chief complaint
- History of present illness with pertinent positives and negatives
- The brief review of systems
- Focused past medical and surgical history
- Focused pertinent medications and allergies
- Very focused family and social history if required
- Vital signs, highlighting any abnormal readings
- Focused and pertinent physical exam
Few helpful hints during documentation
- Place a date and time for 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 Examination
- Avoid using unclear abbreviations that are not used commonly
- 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 name of the physician 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 the medical record after completion. It may be appropriate to add an addendum but only if it is properly 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 AMA to the patient and relatives
- 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 hints apply (Murphy, 2001; Dunbar, 2014; Virtual Mentor, 2011)
Sample ED Note
- Date & time: 06/05/2016 at 07:40
- Arrival Mode: Ambulance
- Source of History: Patient and Spouse
- History Limitations: None
- Chief Complaint: Chest Pain – started 3 hours ago
HPI: A 45-year-old man, with history of Coronary Artery Disease and Hypertension, presenting to the ED with chest pain that started 3 hours ago. The pain was of gradual onset and increased in intensity while sitting on his chair, localized in the center of the chest and lasted for 20 minutes. It was described as “a heavy boulder on my chest.” The pain started when he had a quarrel with his daughter and was relieved with sublingual nitroglycerin. It was associated with nausea, 1 episode of vomiting and sweating. Pain radiated to the left shoulder and arm with numbness of the arm. He claims it was 8/10 on the pain scale. The pain recurred 1 hour prior to ED presentation, and he currently feels dizzy, sweaty with the same chest pain.
- ROS: other than HPI, review of systems is otherwise normal
- PMH: – Hypertension, Dyslipidemia and Coronary Artery Disease (CAD)
– History of Percutaneous Coronary Intervention (PCI) with stent insertion 2 years ago
- Medications and Allergies: on Atorvastatin, Aspirin, Clopidogrel & Sublingual Nitroglycerin, no known allergies
- Family history: Father had Diabetes and CAD, had cardiac arrest and died at the age of 65 years
- Social history: Smoker – 1pack/day for 30 years, denies alcohol consumption or illicit drug use.
- Physical Exam:
- Patient appears to be in moderate distress, is anxious and diaphoretic
- Vitals: BP 130/80 mmHg, PR 120 b/min, RR 20 breaths/min, O2 Sats: 94%
- CVS: symmetrical pulses bilaterally, S1, S2 heard, no murmurs or added sounds, no
lower limb edema
- Resp: Good bilateral air entry, no audible wheezes or crepitations
- Abdomen: soft, non-distended, non-tender, normal active bowel sounds
- Assessment: a 45-Year-old man with typical chest pain, ECG done in triage showed Inferior wall STEMI with ST elevation in leads II, III & AFV as well as T-wave inversion in lead AVL.
- Plan: To order cardiac enzymes, portable chest x-ray, and administer Aspirin, Fentanyl, Heparin, and Ticagrelor
- Disposition: Interventional Cardiologist (Dr. YYY) was contacted at 7:42 AM, Cath lab was activated at 7:45 am. The patient went to the cath lab at 8:15 am.
References and Further Reading
- 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. 2016a [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. 2016b [cited 25 May 2016]. Available from: http://embasic.org/how-to-give-a-good-ed-patient-presentation/
- 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.