The Power of the Pen, Part 1 by Shari Welch, MD
Tuesday, September 7, 2010 
Shari Welch, MDThe Functions of ED Charting
Jim Roberts MD, an emergency physician, writer, an entertaining speaker and humorist describes the medical record for an ED visit this way:
The medical record serves to produce a permanent document that serves to memorialize all the details of a stressful encounter between a group of strangers, some of whom have to prove that they did everything possible to assure the best outcome…
….The only way you can get paid. Medicare and Medicaid and BC/BS know more about charting than you do, and they make their own rules!
“ As any lawyer knows, the ED chart certainly possesses miraculous powers to make them rich beyond their wildest dreams…”
There is some truth to his observations. The medical record has four distinct functions: To document the medical encounter for the purposes of billing and coding. To provide documentation to communicate to other healthcare professionals what occurred on behalf of the patient, what decisions were made and what diagnostic considerations were involved. To allow review for quality purposes. To provide a document that may be used in litigation against the physician or the organization, should there be a suboptimal outcome relative to the healthcare encounter. These four functions are often at odds with one another. In particular charting for billing and coding takes time and attention away from a chart focused on the Plan of care and documentation of converstions with specialists and responses to therapy. Emergency Medicine is a zero sum game and time and energy spent devoted to one task is time away from another. The most important consideration regarding documentation systems is how well does it fit into work flow?
The Four Functions of the ED Chart
- Inform others of the care given
- Justify charges for services
- Allow review for quality assurance purposes
- Defend care against charges in a lawsuit
Charting in the emergency department is an expensive proposition. Most emergency departments generate approximately $500-$600 for each patient seen by the physician in the ED. When a physician is charting he is not seeing a new patient. If an ED physician averages 2.1 patients an hour charting costs nearly $21 dollars a minute! Many health care critics note that physician charting is the equivalent of having the highest trained, highest educated person on the health care team, doing data entry.
The following tables help illustrate the complexities and the detail required in the documentation of care delivered to complex patients in the ED. It is as exhaustive as that required of a hospitalist or internist doing a new patient office note or an admission note to the ICU. An internist gives himself typically 45 minutes to see a new patient for the first time and to document that visit. The ED physician is seeing typically many patients in an hour and spends most of a shift managing 3 or more patients at a time. This same standard of documentation takes the physician from the bedside and away from other critical task. It also likely yields no value to the patient (most ED notes are never read in their entirety).
Physical Exam is done using body part method or organ system method, but they should not be mixed.
How did we get into this mess? Is there a better way? Next month let me tell you about the best options out there.
Reader Comments (1)
These four functions are often at odds with one another. In particular charting for billing and coding takes time and attention away from a chart focused on the Plan of care and documentation of converstions with specialists and responses to therapy.