The Power of the Pen: ED Documentation by Shari Welch, M.D.
Tuesday, August 25, 2009 
Shari Welch, M.D.
“You have to see at least 2.1 patients per hour to keep your skills up.” Where does this come from? ACEP published a pamphlet in 1992 that suggested this number, but it was not based on any rigorous studies. Other leaders suggest 2.5 patients per hour as a reasonable goal for the front lines (Robert A. Rosen, Managing to Get it Right: The ACEP’s User’s Guide to Emergency Department Management, pg 93, ACEP Publications, 1998). Are these numbers realistic today?
Many of the changes we have witnessed in the practice of emergency medicine place constraints on productivity goals. First, the sheer burden of documentation has increased linearly (The Advisory Board, Building the Clockwork ED, 2000). In 1990 the majority of departments were still using paper charting, less than a page for even the most complex patients and often following the simple “SOAP Note” format. Fast forward to the new millennium and increasingly charting is a complex and labor intensive activity for the physician. Increasingly physician charting is becoming part of an overall electronic health record which in many cases was implemented with complete disregard for workflow and detrimental to expedient care. Complex patients now require the documentation of a ten item systems review, an 8 item physical exam, hospital course and medical decision making sections as well as separate documentation of procedures, critical care and observation. Many transcribed reports are three typewritten pages or more! This documentation burden takes time and is increasing!
Endless Charting Is The Rate Limiting Factor for Patient Flow in Many EDs
Additionally, the complexity of care delivered in the acute care setting increases with increasing age. We are just beginning to see baby boomers being added to the geriatric cohort, the fastest growing group to be using ED Services.(ED visits were up 26% for the over 65 age group In the last CDC Advance Data report from HHS). The anticipated increasing complexity of ED patients will mean more work for the staff in the ED and thence more documentation about that work. Many departments are feeling compelled to add observation areas or clinical decision units for evaluating these increased complexity and higher resource utilization patients. This will mean more charting for observation stays and more procedural notes too.
The point is this: Charting is in many places the rate limiting step in an ED visit. The paperwork that accompanies an ED visit (and mind you it is important in terms of billing and coding and risk management) can take more time than the time actually spent at the bedside. Many leaders feel that the best option today for most ED’s is the “hybrid chart”. A combination of a template (to address the checklists to support higher coding levels) and a brief transcribed narrative, to discuss medical decision making and plans. It marries the efficiency of the template and the opportunity to narrate a summary which can help reduce risk.
On the other hand, according to many scribe companies, the proper training and introduction of a scribe program can take physician productivity to over 4 patients an hour! Maybe that is the best answer of all.
Below are some web addresses for scribe programs should you want to learn more about them.
Scribes, Welch, charting in ED Operations, Scribes / Charting
Reader Comments (1)
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