Edward P. Sloan, MD, MPH ED Documentation: A Systematic Approach to the Care of Critically Ill Patients

Edward P. Sloan, MD, MPH

ED Documentation: ED Documentation: A Systematic Approach A Systematic Approach

to the Care of to the Care of Critically Ill PatientsCritically Ill Patients


ICEP Academic ForumICEP Academic Forum

ICEP Research CommitteeICEP Research Committee

Northwestern UniversityNorthwestern University

April 29, 2004April 29, 2004



Associate Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL


Attending PhysicianEmergency Medicine

University of Illinois HospitalOur Lady of the Resurrection Hospital

Chicago, IL


Global ObjectivesGlobal Objectives

• Maximize patient outcomeMaximize patient outcome• Enhance ED critical thinkingEnhance ED critical thinking• Provide a powerful recordProvide a powerful record

• Optimize peace of mindOptimize peace of mind• Improve clinical practiceImprove clinical practice• Increase career longevityIncrease career longevity


Sessions ObjectivesSessions Objectives

• Review critical care ED caseReview critical care ED case• Examine ED documentationExamine ED documentation• Compare to consultants Compare to consultants • Decide how to optimize our Decide how to optimize our

record keeping in the EDrecord keeping in the ED• Develop a specific planDevelop a specific plan


A Case:A Case:22 yo Found22 yo Found

Unconscious Unconscious on the Flooron the Floor


CFD HistoryCFD History

- 1841 HR 90, RR 101841 HR 90, RR 10- Patient found unconscious Patient found unconscious

on the floor, pants down on the floor, pants down around his knees…IV line, around his knees…IV line, narcan, it took over two narcan, it took over two minutes for pt to become minutes for pt to become CAO x 3…transport…CAO x 3…transport…


RN NoteRN Note- 140/110 150s 24 99.6140/110 150s 24 99.6ºº- No drugs No drugs - No chest painNo chest pain- Pt has vials of white powderPt has vials of white powder- Respirations unlaboredRespirations unlabored- Patient says he feels finePatient says he feels fine


Attending NoteAttending Note7:50 22 yo7:50 22 yo

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


Physical ExamPhysical Exam= pt alert, NAD= pt alert, NAD

= VS Noted Inc HR, Dec O2 sat, No inc RR= VS Noted Inc HR, Dec O2 sat, No inc RR

= No toxidrome evident= No toxidrome evident

= Head: pupils E/R EOM OK, airway OK= Head: pupils E/R EOM OK, airway OK

= Neck: supple, no crep= Neck: supple, no crep

= Chest: ?clear, BSB=, few rhonchi= Chest: ?clear, BSB=, few rhonchi

= Cor: rapid without= Cor: rapid without


Physical Exam Physical Exam

= Abd: soft, NT= Abd: soft, NT

= Ext: non-tender, no calf tenderness= Ext: non-tender, no calf tenderness

= Neuro: Appropriate MS, speech= Neuro: Appropriate MS, speech

NOT post-ictalNOT post-ictal

NO IVDA marksNO IVDA marks

No tongue traumaNo tongue trauma

= pulse ox 88% RA= pulse ox 88% RA


Sick?Sick?

Not sick?? Not sick??


Workup??Workup??


Provisional Provisional Diagnoses??Diagnoses??


Differential Differential Diagnosis??Diagnosis??


Problem List??Problem List??


Problem ListProblem List

- Altered Mental statusAltered Mental status- R/o syncope R/o syncope - R/o seizureR/o seizure- R/o drug, EtOH ingestionR/o drug, EtOH ingestion- R/o traumaR/o trauma- R/o metabolic abnormalityR/o metabolic abnormality



- TachycardiaTachycardia- R/o cardiac dysrhythmiaR/o cardiac dysrhythmia- R/o dehydrationR/o dehydration- R/o drug, EtOH ingestionR/o drug, EtOH ingestion- R/o trauma, hemorrhagic shockR/o trauma, hemorrhagic shock- R/o metabolic abnormalityR/o metabolic abnormality



- HypoxiaHypoxia- R/o cardiac etiology, ie CHFR/o cardiac etiology, ie CHF- R/o ARDSR/o ARDS- R/o pneumoniaR/o pneumonia- R/o PER/o PE- R/o bronchospasmR/o bronchospasm


Problem ListProblem List- Pants around the anklesPants around the ankles

- R/o ….R/o ….- R/o ….R/o ….- R/o ….R/o ….- R/o ….R/o ….- R/o “funny business of some R/o “funny business of some

sort”sort”


The UpshotThe 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


Your ED DocumentationYour ED Documentation

• Compelling

• Complete

• Systematic

• Involves data integration

• Provides accountability

• Improves care


Clinical QuestionsClinical 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?


How Did the Patient Present?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


What Was Your Problem List?What Was Your Problem List?

• Respiratory distress • Bronchospasm with hypoxia • Bilateral pneumonia• Altered mental status

• First diagnoses symptom-based


What Was the Differential Dx?What Was the Differential Dx?

• Hypoxia due to: •Bronchospasm•Bronchopneumonia•Pulmonary embolism•Exacerbation COPD•ARDS•Toxic inhalation

• Determines ongoing therapies


What Work-up Did You Do?What Work-up Did You Do?

• What tests? • What results? • What interpretation?• What need for therapy?

• Interpret and treat, not annotate


What Rx Did You Provide?What Rx Did You Provide?

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

• What didn’t you do?


What Was Your Disposition?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?


Why?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-MakingMedical Decision-Making

• Problem List

• Differential Diagnosis

• ED Therapies Provided

• ED Testing Provided

• Response to Therapy

• Repeat Exam



• Consultations Provided

• Disposition

• Patient Status at Disposition

• ED Diagnoses

• Follow-up

• Discharge medications

• Patient/Family Understanding


Our ConsultantsOur 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 LearningConsultants: 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


Optimizing ED DocumentationOptimizing ED Documentation

• Develop a systematic process

• Follow rigid principles

• Treat variance as an exception

• Continue to reassess the process


A Specific ProcessA Specific Process

• Part 1: Assess the pt, problem

• Part 2: Treat, assess response

• Part 3: Summarize, disposition

• Do it all over again


Part 1: Assess Pt, ProblemPart 1: Assess Pt, Problem

• Read the triage note

• Go to the bedside

• Write a note

• Go to the computer

• Develop a differential

• Consider options


Part 2: Treat, Reassess Part 2: Treat, Reassess

• Treat the patient

• Interpret the results

• Reassess the patient

• Obtain consultations

• Document the results


Part 3: Summarize, DispoPart 3: Summarize, Dispo

• Complete the problem list

• Assess remaining issues

• Document status, likely outcome

• Identify relevant W’s


Optimizing ED Care & MDMOptimizing ED Care & MDM

• Write to think

• Medical record: working document

• Use multiple sheets of paper

• Don’t scribble

• Write your problem list early

• Complete medical decision making

• Allow your writing to influence you


Optimizing ED Care & MDMOptimizing 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


ED MDM PrinciplesED 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


ED MDM PrinciplesED MDM Principles

• Be a problem solver

• Personalize the approach

• Be systematic

• Assess risk

• Make decisions

• Document why decisions are made

• First do no harm


Your Specific ED PlanYour Specific ED Plan

• Know your own style

• Know what options exist

• Plan to enhance document

• Utilize paper

• Consider preformatted sheets

• Consider dictation


Documenting MDMDocumenting 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


The T-SystemThe T-System

• 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?


The Retrospective LookThe 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?


Retrospective PerspectiveRetrospective 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!



• Problem List•Altered Mental Status

•Hypoxia

•Tachycardia

•R/o syncope

•R/o toxic inhalation

•R/o BHT/TIA/CVA/Sz

•R/o ARDS, pneumonia



• 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



• Response to Therapy•Pt still tachycardic

•No respiratory distress

•Mental status improved

• Repeat Exam•Lungs BSBE with wheezes

•No focal neurologic findings



• Consultations Provided•ID: levoquin added

•Pulmonary: start lovenox

• Disposition•Admitted to ICU

• Patient Status at Disposition•Stable, but still tachycardic, MS ok



• 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



• ED Diagnoses•Altered mental status

•Hypoxia due to bronchospasm

•Likely pulmonary embolism

•Bilateral pneumonia vs ARDS

•R/o toxic ingestion/inhalation


Some MDM Chart ExamplesSome 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



• Patient defers admit x2 NCI

• Pt defers admit, despite need

• Close follow-up with PMD

• Pt, PMD aware of plans



• 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


ConclusionsConclusions

• 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


Questions?Questions?

[email protected] 413 7490

2004icep academic forum criticalcaredoc show.PPT

Documents

Edward P. Sloan, MD, MPH ED Documentation: A Systematic Approach to the Care of Critically Ill Patients