Check-off Charting: Boon or Bust?

Change may be needed in emergency department patient charting

By Bruce David Janiak, MD, FACEP, FAAP, Vice Chairman and Professor of Emergency Medicine, Medical College of Georgia, Augusta.

Editor’s note: Dr. Janiak has been involved in medical-legal consulting for almost three decades. In the following article, he shares his insights about template charting.

There are, of course, a number of chart documentation methods and the goals of the various methods are all the same: 1) to memorialize the patient encounter for future reference by other caregivers; 2) to provide information for billing purposes; and 3) to create a legal document that allows quality review whether in the medical setting or in the courtroom. The three main methodologies for accomplishing the task are handwritten notes, transcription (dictation or voice-activation), and check-off templates (paper or electronic). Each method varies in its ability to satisfy the three main goals of documentation.

Let the reader be aware that this author prefers dictation and considers it the best and most risk-free compromise. Even though the check-off template systems have found a significant following and popularity, they have specific advantages and drawbacks that deserve discussion.

The check-off or template record was developed to solve two major problems: the inordinate expense of dictation and the failure of emergency physicians to document appropriately for both clinical and billing purposes. The fact that a great many EDs in this country use such a template record system is a testament to its success. However, as with any process or system, there can be problematic issues, some of which are philosophical and some of which are practical.

How the template process works

The process of recording a patient’s history and physical in a template can be simple and is accomplished (in some systems) by first selecting a template geared to his/her chief complaint (e.g., “chest pain” or “shortness of breath”). The physician then usually is prompted to answer, by checking a “yes” or “no” box, numerous questions regarding the history of the patient’s present illness and review of systems. Answers that do not fit into this format can then be elaborated on by handwriting notes on the limited space on the form (or by using dictation). For the most part, the physical exam is dealt with in the same way by using a physical exam template. Other documentation systems may use a generic template format for every patient, that is, every template is general in terms of its questions, and specific complaint-related issues must be addressed or expanded upon by handwritten notes. All such systems, however, rely, at least in part, on hand written notes to record issues such as “medical decision-making” and “course in the emergency department.” It is in this process that a significant problem exists. It is the patient’s course in the emergency department and the narrative about decision-making that provides much of the data used to defend cases. Reading a note that indicates a patient was re-evaluated after lab and imaging offers more supportive material for the defense expert than checked boxes that may imply the same thing.

Time is a factor

Dictated records take time to transcribe, and the information may not be available to admitting physicians. Template records are immediately available to any physicians subsequently caring for the patient or for billing and coding because they are most commonly completed contemporaneously. Of course, dictations ideally should be completed as soon as possible, but depending on the time of day, transcriptions may not be available for many hours.

Too many template choices?

Having had the opportunity to work with a number of different template charts, those that are generated by the patient’s chief complaint are at risk of causing some confusion or inefficiencies. For instance, it is a common practice for a nurse or clerk to compile an emergency chart by selecting a seemingly appropriate template according to the chief complaint of the patient. If the physician feels another template would have been more appropriate, inefficiency occurs as a more applicable template is selected prior to beginning documentation. Alternately, the physician may continue to use the nurse-selected template and attempt to make it a better fit to the patient’s complaint by handwritten supplement.

Even when the deficit is corrected by making additional handwritten notes, there may be some “explaining to do” if the eventual diagnosis correlates better with the nurse’s selection than the doctor’s. Since handwriting can be notoriously difficult to read, this also may make the subjective and narrative part of the document less valuable. Using a generic template solves part of the problem, but it still relies on handwriting to fill in the information gaps. In summary, the highest paid person in the department (the physician) is forced to compensate for the template’s lack of subjectivity by time-consuming handwriting. In the real world, this task often gets “short-shift” in a busy department, resulting in a less defensible record.

Creating a complete review with the template

When boxes are checked appropriately, they serve to communicate certain important elements effectively. When checked inappropriately, they can spell medical-legal disaster. If one checks the box “I have seen and agree with the nurse’s note,” he or she must be certain that statement is true. In a missed myocardial infarction (MI) case, a nurse’s reference to chest pain may carry more credibility than a doctor’s note that states “no chest pain” but also states “agree with nurse’s note.” When the eventual diagnosis is MI and the doctor “agreed with the nurse’s note,” defense is difficult. More than once, I have reviewed nurses’ notes that reference a significant abnormal finding that was not addressed in the doctor’s note. If that abnormal finding is a critical issue in a lawsuit, the plaintiff may have the upper hand.

Additionally, sometimes a back or forward slash gets confused, or the direction of the slash is indeterminate. To make the task of completing a template more efficient, questions may be answered by a forward slash (/) in the box meaning “negative,” or a backward slash (\) meaning “positive.” “Positive” slashes usually require written explanation. In one case, an emergency physician inadvertently “slashed” in the wrong direction, indicating the existence of a penetrating injury to the globe of the eye even though he, in fact, believed that he was dealing with a simple corneal abrasion. Unfortunately, the patient did end up with a penetration and the case could not be defended. (This case never went to trial or discovery.) Therefore, if an inappropriate “slash” is linked to a critical issue in a lawsuit, settlement may be the only choice.

More subtly, I have seen a case where the “NAD” (“no acute distress”) box was checked. During the ED course, the patient was given narcotic injections twice for pain. There was no explanation given as to why someone in “no acute distress” was given narcotics. Perhaps there was a reasonable explanation, but the chart gave no indication. Remember that a defense expert needs a record that is credible to offer vigorous support in court. If there were other issues in the patient record that focus on credibility (e.g., patient had chest pain but no ECG was ordered), the defense expert may choose to advise settlement or refuse to defend all together.

Since the subjective part of the ED record is addressed by adding hand-written notes, and since handwriting is time consuming, it should come as no surprise that emergency physicians often make their handwritten portion too brief. There is no doubt that checking a box is efficient, at least in paper format. The issue actually is ensuring that a complete recording of the subjective information is given so as to “connect the dots” or to tell a story of the patient’s ED encounter that makes sense. In my experience, the defense bar prefers a dictated note over a check-off template because they have similar concerns about the replacement of a subjective narrative with a simple “yes” or “no.” In reviewing cases, I have struggled over the handwritten portion of the template all too often, finding that the vital subjective information was both illegible and inadequate. This forced the defense team to rely in too great a measure on the statements in the defendant’s deposition, often taken a year or two years after the patient encounter occurred.

So why isn’t dictation for everyone?

Because of cost (several dollars per patient), hospitals often prefer the cheaper template (a dollar or less per patient) over dictation. ED groups are pressured to save the institution money, and they may embrace the template for this reason. Also, many ED doctors do not like to dictate or may never have learned the technique because a template format was used in their training programs. Certainly, the ability of the check-off sheet to list sufficient elements for billing and coding purposes is a big plus; however, dictation guides that address levels of service and elements of the review of systems and physical exam are available and can accomplish the same level of compliance with recording “elements” as a template. Additionally, there is a perception that dictation takes longer, but to my knowledge there are no truly comparative studies.


So, is there any documentation process that is legible, defendable, cheap, easily codeable, and quick? I suspect a combination of check-off charts and dictation may be an answer. The template sheet could be used for minor problems, while dictation could be employed for complaints related to the chest or abdomen, for example, or for the elderly or otherwise complicated patients. The key, as far as I am concerned, is to improve the subjective part of charting. Can I, by reading the chart, glean the thought process of the emergency physician, the patient’s course in the ED, and the reason certain diseases in the differential were not pursued? There are very few who would be able to convey this information by hand written notes alone. In many legal cases I have reviewed, the defendant ED physician had to supplement these charting deficiencies with deposition testimony, relying on the memory of interactions that occurred long ago. In the dictated chart, the physician can tell the story of his/her thought process in a believable way.

For example, “although the patient had pleuritic pain and was pregnant, the pain was intermittent, there was no tachycardia or hemoptysis, and I do not believe she is suffering from a pulmonary embolus” or “I discussed the possibility of appendicitis with the parents, telling them it was unlikely, but advising them to return if any concerns.” Or as another example, “I called the primary care physician and discussed the case with him, and we decided that office follow-up tomorrow is reasonable.” None of these dictations is a guarantee of legal protection, but they go a long way to establishing credibility with the jury.

Perhaps emergency medical voice-activated dictation eventually will become a viable alternative. Current applications require “training” of the system to the user’s voice and still require too much emergency physician keyboard time. Until then, a compromise solution as indicated above may be the best we can do.

The emergency chart memorializes a patient encounter and it is our best defense against an allegation of malpractice. Continued critical analysis of our documentation methodology is indicated.