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Does Your Charting Explain Your Medical Reasoning?
Gabor D. Kelen, MD, director of the Department of Emergency Medicine at The Johns Hopkins University in Baltimore, says that one area of documentation he feels is too often shortchanged involves the ED physician's medical reasoning.
"This takes the longest to document," he says. "I might not remember every piece of history I asked, or every part of the physical exam that I did, even with computer guidance," he says. "But I spend most of my time on medical reasoning."
Medical reasoning explains the ED physician's thought process. "I document, 'the conditions and situation I considered, why I do think it's this or why I can't exclude a certain important consideration, and here's why I don't think it's various other conditions,'" says Kelen. "I believe that if something should go wrong, if in my documentation I explain that I considered a condition and why I didn't pursue it, at least I have given a good medical opinion."
Following this format will explain, for example, why an ED physician discharged a patient after arranging for outpatient follow-up, or cautioned the patient that while he couldn't be 100% sure about a certain outcome, he believed it was very low risk.
Another good reason to document medical decision making is better communication with other health care providers. "Sometimes the inpatient guys [based on charting] have no idea why we admitted the patient. The medical decision making helps them know what I have already considered, and what my real concerns were," says Kelen.
The same is true if the patient was discharged from the ED. "If I sent the patient out, the outpatient doctor can see that my workup reasonably excluded or addressed some conditions," says Kelen. "They have some way to understand what your thinking is. That's probably the most important part of documentation."
Another common problem area is the failure to document your acknowledgement of vital signs. "Sometimes people look at the very first vital signs and fail to note an abnormality," says Kelen. "It's not like you can't send the patient home with an abnormal vital sign. You certainly can, but you better explain in your notes why it's okay."
Never omit an explanation of any and all critical abnormalities that you find. A patient may come in with chest pain and during your examination you find abdominal pain.
"Just because they came in with chest pain doesn't mean that somewhere in your notes you don't have to explain what you think the abdominal pain is about," says Kelen. "Otherwise it just looks like you didn't look at it, or if you did look at it, you didn't understand its implications."
It should be obvious to anyone reading the chart that you acknowledged an abnormality, looked at it and had some understanding of the implications, says Kelen. "Every acute abnormality should be explained somewhere in your notes," he says.