Often, a portion of the history, assessment, or evaluation was handled, but for whatever reason does not make it into the emergency medicine (EM) record. “A thorough H&P, simply stated, is often lacking in EM charts,” says Bryan Baskin, DO, FACEP, assistant professor of medicine at Cleveland Clinic Lerner College of Medicine and associate quality improvement officer for Cleveland Clinic’s Emergency Services Institute.

This makes it appear as though a poor or incomplete assessment was conducted. Baskin often sees ED charts missing these important items:

  • Review of risk factors for coronary artery disease, acute coronary syndrome, pulmonary embolism (PE), stroke, or spinal infections. For instance, if PE is on the differential, Baskin says the chart should show the EP reviewed PE risk factors, and used a decision rule such as the Pulmonary Embolism Rule-out Criteria (PERC).
  • Specific exams that are relevant to the patient’s chief complaint. No evidence of abdominal and vascular exams in a patient with chest pain or no evidence of a thorough neurological exam in a patient with headache can lead to legal trouble.
  • Medical decision-making. Many charts lack appropriate rationale for the care that was rendered, or any insight on why the EP decided on a specific workup, treatment, or disposition. “This is an area where ED charts typically fall short,” Baskin observes.
  • Reassessments. “These are an important part of EM charts. They show thoroughness,” Baskin says. Examples include repeat abdominal, respiratory, or neurological exams. These often are completed, but are not documented, so it is questionable whether they occurred.
  • Discharge instructions. Many charts are light on specifics. Nowhere does it indicate exactly who, where, and when the patient should be following up. This can be stated simply, according to Baskin. For example, the EP might chart: “Follow up with cardiology in one week’s time.”

Charts also omit specifics on signs and symptoms to watch for, and what should bring them back to the ED in a hurry. Baskin likes to see specifics such as “If headache reoccurs, changes, or worsens, or you develop weakness or numbness.”

“Interestingly, in many med/mal cases, the discharge instructions are a highly reviewed portion of the medical review,” Baskin reports. Demonstrating that a good assessment was conducted can be more challenging if the ED visit is brief. Leaders view a short length of stay positively, an indication of efficient processes and good patient flow.

“However, in the event of a bad outcome, a plaintiff may later allege a short length of stay means the evaluation was rushed or incomplete,” says Melanie Heniff, MD, JD, FACEP, FAAP, assistant professor of clinical emergency medicine at Indiana University School of Medicine.

Good documentation of discharge instructions shows the opposite was true. “The chart should convey that enough time was spent with the patient,” Heniff offers.

The discharge instructions should show the EP explained what the patient needed in terms of further evaluation and treatment, even though this was not immediately necessary at the time of the ED visit.

Some ED patients are initially described as “in distress” or “ill-appearing,” but eventually improve enough to be discharged. For these patients, documentation of re-assessment and improvement (in symptoms and in abnormal vital signs) is “critical,” according to Heniff. “This is particularly true when a patient is in the ED for a long period.”