ED Documentation: A Systematic Approach to the Care of Critically Ill Patients

1. ED Documentation: A Systematic Approach to the Care of Critically Ill Patients

2. ICEP Academic ForumICEP Research CommitteeNorthwestern UniversityApril 29, 2004

3. Edward P. Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

4. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL

5. Global Objectives • Maximize patient outcome • Enhance ED critical thinking • Provide a powerful record • Optimize peace of mind • Improve clinical practice • Increase career longevity

6. Sessions Objectives • Review critical care ED case • Examine ED documentation • Compare to consultants • Decide how to optimize our record keeping in the ED • Develop a specific plan

7. A Case:22 yo FoundUnconscious on the Floor

8. CFD History • 1841 HR 90, RR 10 • Patient found unconscious on the floor, pants down around his knees…IV line, narcan, it took over two minutes for pt to become CAO x 3…transport…

9. RN Note • 140/110 150s 24 99.6º • No drugs • No chest pain • Pt has vials of white powder • Respirations unlabored • Patient says he feels fine

10. Attending Note 7:50 22 yo = CFD pt = AMS? Syncope? = Related to drug? = Pt denies all drug use = No trauma = No known etiology of syncope = No other complaints

11. Physical Exam = pt alert, NAD = VS Noted Inc HR, Dec O2 sat, No inc RR = No toxidrome evident = Head: pupils E/R EOM OK, airway OK = Neck: supple, no crep = Chest: ?clear, BSB=, few rhonchi = Cor: rapid without

12. Physical Exam = Abd: soft, NT = Ext: non-tender, no calf tenderness = Neuro: Appropriate MS, speech NOT post-ictal NO IVDA marks No tongue trauma = pulse ox 88% RA

13. Sick?Not sick??

14. Workup??

15. Provisional Diagnoses??

16. Differential Diagnosis??

17. Problem List??

18. Problem List • Altered Mental status • R/o syncope • R/o seizure • R/o drug, EtOH ingestion • R/o trauma • R/o metabolic abnormality

19. Problem List • Tachycardia • R/o cardiac dysrhythmia • R/o dehydration • R/o drug, EtOH ingestion • R/o trauma, hemorrhagic shock • R/o metabolic abnormality

20. Problem List • Hypoxia • R/o cardiac etiology, ie CHF • R/o ARDS • R/o pneumonia • R/o PE • R/o bronchospasm

21. Problem List • Pants around the ankles • R/o …. • R/o …. • R/o …. • R/o …. • R/o “funny business of some sort”

22. The Upshot Your work is compelling So must be your documentation You do medical decision making You must document MDM All systems make this difficult You must, therefore, be systematic

23. Your ED Documentation Compelling Complete Systematic Involves data integration Provides accountability Improves care

24. Clinical Questions How did the patient present? What was your problem list? What was your Differential Dx? What work-up did you do? What Rx did you provide? What was your disposition? WHY?

25. How Did the Patient Present? Establishes baseline status Explains, in part, outcome Determines need for Rx Most important in critical illness This is your H & P Pain or respiratory distress

26. What Was Your Problem List? Respiratory distress Bronchospasm with hypoxia Bilateral pneumonia Altered mental status First diagnoses symptom-based

27. What Was the Differential Dx? Hypoxia due to: Bronchospasm Bronchopneumonia Pulmonary embolism Exacerbation COPD ARDS Toxic inhalation Determines ongoing therapies

28. What Work-up Did You Do? What tests? What results? What interpretation? What need for therapy? Interpret and treat, not annotate

29. What Rx Did You Provide? What therapies? What result? What response to therapy? Did the patient stabilize? What didn’t you do?

30. What Was Your Disposition? Who did you talk to? Where did your patient go? What was the expected outcome? What was the patient’s status? Who knew what? Agreement?

31. Why? Why did you do what you did? What was clinically indicated? What patient preference? What opportunities to maximize patient outcome were provided? What uncertainty? What decisions given uncertainty?

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36. Medical Decision-Making Problem List Differential Diagnosis ED Therapies Provided ED Testing Provided Response to Therapy Repeat Exam

37. Medical Decision-Making Consultations Provided Disposition Patient Status at Disposition ED Diagnoses Follow-up Discharge medications Patient/Family Understanding

38. Our Consultants Stop and look at big picture Consider all possibilities Look forward at next steps More of a medicine approach Completeness; More R/o Dx Not necessarily better per se Consultants look “smarter”

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46. Consultants: MDM Learning Step back and think like one Put your thoughts on paper Include plenty of R/o s Think like “the other guy” Initiate ongoing therapies Make it easy to transfer care List every possible Dx

47. Optimizing ED Documentation Develop a systematic process Follow rigid principles Treat variance as an exception Continue to reassess the process

48. A Specific Process Part 1: Assess the pt, problem Part 2: Treat, assess response Part 3: Summarize, disposition Do it all over again

49. Part 1: Assess Pt, Problem Read the triage note Go to the bedside Write a note Go to the computer Develop a differential Consider options

50. Part 2: Treat, Reassess Treat the patient Interpret the results Reassess the patient Obtain consultations Document the results