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

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ED Documentation A Systematic Approach to the
Care of Critically Ill Patients
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ICEP Academic ForumICEP Research
CommitteeNorthwestern UniversityApril 29, 2004
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Edward P. Sloan, MD, MPHAssociate
ProfessorDepartment of Emergency
MedicineUniversity of Illinois College of
MedicineChicago, IL
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Attending PhysicianEmergency
MedicineUniversity of Illinois HospitalOur
Lady of the Resurrection HospitalChicago, IL
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Global Objectives

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

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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

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A Case22 yo FoundUnconscious on the Floor
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CFD History

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

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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

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Attending Note

• 750 22 yo
• CFD pt
• AMS? Syncope?
• Related to drug?
• Pt denies all drug use
• No trauma
• No known etiology of syncope
• No other complaints

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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

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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

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Sick?Not sick??
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Workup??
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Provisional Diagnoses??
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Differential Diagnosis??
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Problem List??
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Problem List

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

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Problem List

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

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Problem List

• Hypoxia
• R/o cardiac etiology, ie CHF
• R/o ARDS
• R/o pneumonia
• R/o PE
• R/o bronchospasm

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Problem List

• Pants around the ankles
• R/o .
• R/o .
• R/o .
• R/o .
• R/o funny business of some sort

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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

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Your ED Documentation

• Compelling
• Complete
• Systematic
• Involves data integration
• Provides accountability
• Improves care

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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?

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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

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What Was Your Problem List?

• Respiratory distress
• Bronchospasm with hypoxia
• Bilateral pneumonia
• Altered mental status
• First diagnoses symptom-based

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What Was the Differential Dx?

• Hypoxia due to
• Bronchospasm
• Bronchopneumonia
• Pulmonary embolism
• Exacerbation COPD
• ARDS
• Toxic inhalation
• Determines ongoing therapies

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What Work-up Did You Do?

• What tests?
• What results?
• What interpretation?
• What need for therapy?
• Interpret and treat, not annotate

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What Rx Did You Provide?

• What therapies?
• What result?
• What response to therapy?
• Did the patient stabilize?
• What didnt you do?

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What Was Your Disposition?

• Who did you talk to?
• Where did your patient go?
• What was the expected outcome?
• What was the patients status?
• Who knew what? Agreement?

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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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Medical Decision-Making

• Problem List
• Differential Diagnosis
• ED Therapies Provided
• ED Testing Provided
• Response to Therapy
• Repeat Exam

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Medical Decision-Making

• Consultations Provided
• Disposition
• Patient Status at Disposition
• ED Diagnoses
• Follow-up
• Discharge medications
• Patient/Family Understanding

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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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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

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Optimizing ED Documentation

• Develop a systematic process
• Follow rigid principles
• Treat variance as an exception
• Continue to reassess the process

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A Specific Process

• Part 1 Assess the pt, problem
• Part 2 Treat, assess response
• Part 3 Summarize, disposition
• Do it all over again

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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

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Part 2 Treat, Reassess

• Treat the patient
• Interpret the results
• Reassess the patient
• Obtain consultations
• Document the results

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Part 3 Summarize, Dispo

• Complete the problem list
• Assess remaining issues
• Document status, likely outcome
• Identify relevant Ws

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Optimizing ED Care MDM

• Write to think
• Medical record working document
• Use multiple sheets of paper
• Dont scribble
• Write your problem list early
• Complete medical decision making
• Allow your writing to influence you

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Optimizing ED Care MDM

• Document change in status or plan
• Pretend you are the consultant
• Disposition with multiple diagnoses
• Write as you talk
• Write as you assess
• Write as you interpret
• Write as you think

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ED MDM Principles

• Everything good happens at the patient bedside
• Give no advice without seeing the patient
• Make no decisions without writing in the medical
  record
  
• Act not on what the problem likely is, but what
  it could be
  

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ED MDM Principles

• Be a problem solver
• Personalize the approach
• Be systematic
• Assess risk
• Make decisions
• Document why decisions are made
• First do no harm

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Your Specific ED Plan

• Know your own style
• Know what options exist
• Plan to enhance document
• Utilize paper
• Consider preformatted sheets
• Consider dictation

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Documenting MDM

• Pen and paper is best
• Dictate only your H and P
• Write medical decision making
• Know when each gets to the chart
• Know when discrepancies exist
• Careful not to over-include data

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Pre-formatted Systems

• Quick and efficient
• Limited writing
• Limited medical decision making
• Why did you do what you did?
• What do others need to know?
• Who knew what when? Why?

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The Retrospective Look

• The chart will have scribbles
• Some things will be missing
• MDM will be unsubstantiated
• Consults will be under-documented
• Awareness will be rarely listed
• Deposition what were you thinking?

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Retrospective Perspective

• Does it matter? Yes
• Must you strive for perfection? Yes
• Will you achieve perfection? No
• Can you do more than develop a system for
  minimizing errors? No
  
• Do your best, forget the rest!

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Medical Decision-Making

• Problem List
• Altered Mental Status
• Hypoxia
• Tachycardia
• R/o syncope
• R/o toxic inhalation
• R/o BHT/TIA/CVA/Sz
• R/o ARDS, pneumonia

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Medical Decision-Making

• Differential Diagnosis (see above)
• ED Therapies Provided
• O2, albuterol, fluid bolus
• Lovenox, antibiotics
• ED Testing Provided
• EKG, CXR, CT, ABG, Labs
• Interpretations
• Hypoxia, hypercarbia, tachycardiaa

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Medical Decision-Making

• Response to Therapy
• Pt still tachycardic
• No respiratory distress
• Mental status improved
• Repeat Exam
• Lungs BSBE with wheezes
• No focal neurologic findings

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Medical Decision-Making

• Consultations Provided
• ID levoquin added
• Pulmonary start lovenox
• Disposition
• Admitted to ICU
• Patient Status at Disposition
• Stable, but still tachycardic, MS ok

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Medical Decision-Making

• Discharge medications
• Further Rx per PMD, consultants
• Patient/Family Understanding
• Patient and family aware of clinical status and
  need for ICU care
  
• Critical care time of 45 minutes

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Medical Decision-Making

• ED Diagnoses
• Altered mental status
• Hypoxia due to bronchospasm
• Likely pulmonary embolism
• Bilateral pneumonia vs ARDS
• R/o toxic ingestion/inhalation

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Some MDM Chart Examples

• PMD notified, cards prn
• CT NCI, deferred by pt, family
• Ongoing therapy per cards
• Pt critically ill, but stable
• Family aware of critical illness and likely
  demise
  
• Further Rx deferred, DNR signed

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Some MDM Chart Examples

• Patient defers admit x2 NCI
• Pt defers admit, despite need
• Close follow-up with PMD
• Pt, PMD aware of plans

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Some MDM Chart Examples

• Out AMA
• Pt wants to see PMD in AM
• Aware of risks including death
• Judgment not clinically impaired
• All optimal therapies provided
• May return at any time
• High risk symptoms explained

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Conclusions

• Documentation is everything
• Extemporaneous info is king
• Develop a system
• Be systematic
• Do it real-time
• Be comfortable with writing
• Let the process guide your thinking

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Questions?
edsloan_at_uic.edu 312 413 7490 2004icep academic
forum criticalcaredoc show.PPT