Should ED staff ask patients to document?

By using a patient medical record form that includes patient documentation, communication is much clearer between patients and staff, reports Gwyn M. Parris-Atwell, RN, MSN, NP-C, CS, CEN, clinical educator for emergency services at South Jersey Health System in Bridgeton, NJ.

"Patients are more involved because the form requires their input," she explains. "They have the opportunity to document in their own words so they feel they have more input."

The form eliminates the need to ask patients for their names, chief complaints, and medical histories numerous times, says Michelle Regan Donovan, RN, BSN, president of Millennium Strategies, a health care consulting firm in Charlottesville, VA.

As the organization’s emergency services consultant, Donovan helped develop a medical record form that allows patients to start documentation at triage. "Previously, there was a great deal of wasted or duplicated documentation required by both physicians and nursing staff, often resulting in poor-quality reviews," she says.

The goal is to obtain necessary triage information which would, in turn, be available to the physician during his interview process, Donovan explains.

To avoid duplication, patients provide information for the social history and discharge documentation by completing the form in the triage area and examination room, says Parris-Atwell. "We went through the chart with a fine-tooth comb to eliminate any redundancy," she says.

The physician may need to clarify some of the information, but because the information is already on the front sheet, they should not have to go back and repeat the questions, says Parris-Atwell.

Patients appreciate not being asked the same questions over and over again, she says. "We get the information upfront and verify it once to make sure it’s correct. The physician can simply review the information without asking the entire history again."

The form used at St. Vincent’s allows the patient or family to give detailed history, including names of physicians, surgeons, cardiologists, medications, and previous surgeries, says Ralph Badanowski, MD, FACEP, the ED’s medical director.

"It’s similar to the form you fill out when you see your own personal caregiver," he says. "This avoids delay in notification of the right consultant."

Patients or family fill out the form in triage or in the treatment room if they arrive by ambulance, he says. "It is optional, but we get 75% compliance. They want you to know their medical history."

The value of the information can be indispensable, Badanowski says. "For example, consider the patient on insulin who does not consider this a medication and neglects to mention this, or the patients with allergies," he explains.

On discharge, medication mistakes can be avoided because allergies, pregnancy, or pre-existing conditions are clearly noted, he says. "The patient with multiple risk factors for heart trouble or stroke can be quickly identified at triage, so that time-sensitive treatments such as thrombolytics will not be delayed."

Occasionally, there is a problem with accuracy or legibility of the information patients provide, notes Parris-Atwell. "At times, the information is not correct, and there is sometimes a language barrier," she says. "Under today’s problem,’ they may write, I’m sick,’ so we may need to get more information."

Concerns were raised regarding the numbers of patients who might need assistance in filling out the items due to illiteracy or language barriers, notes Donovan. "Registration clerks, who are often bilingual, and/or security officers stationed at the door and proximal to the triage area may direct or assist patients with this process as necessary," she says.

Patient information occasionally needs to be translated into medical terminology, says Parris-Atwell. "Sometimes, we have difficulty with how they describe something," she notes. "When the physician comes in, [patients] can repeat what they have written to clarify it. What we may call gastric,’ they may call belly.’"

The patient medical profile form used by St. Vincent’s Medical Center in Jacksonville, FL, includes a box asking whether the physician has reviewed the questionnaire, says Badanowski. "The physicians check the box or initial the form to document they read it."

If the information is inaccurate, the inaccuracy needs to be addressed in the documentation, he says. "The physician documents the past medical history, social history, and family history, so corrections are made there," he explains, adding that if the physician suspects a patient has filled out the form incorrectly, the physician asks the patient to confirm his or her answers. 

Sources

  • Ralph Badanowski, MD, FACEP, Emergency Department, St. Vincent’s Medical Center, 1800 Barrs St., Jacksonville, FL 32204. Phone: (904) 308-8435. Fax: (904) 308-2984. E-mail: Badralph@aol.com.
  • Sandra Dietrich, RN, MSN, South Jersey Health System, Emergency Services, 333 Irving Ave., Bridgeton, NJ 08302. Phone: (856) 825-3500, ext. 3456. Fax: (856) 327-8085. E-mail: dietrichs@sjhs.com.
  • Michelle Regan Donovan, RN, BSN, Millennium Strategies Inc., 977 Seminole Trail, Suite 274, Charlottesville, VA 22901. Phone: (540) 923-4799. Fax: (540) 923-4045. E-mail: emergencyconsult@aol.com.
  • Gwyn M. Parris-Atwell, RN, MSN, NP-C, CS, CEN, Department of Education, South Jersey Health System, Department of Education, 333 Irving Ave., Bridgeton, NJ 08302. Phone: (856) 575-4538. Fax: (856) 453-1218. E-mail: Parris-AtwellG@SJHS.com.