What information should be included in documentation after an emergency room (ER) consultation at a hospital?

Documentation Requirements After Emergency Room Consultation

After an emergency room consultation, documentation must include a time-based record of the clinical encounter with specific focus on: the reason for consultation, pertinent history and physical findings, assessment with severity classification, treatment provided with medications/dosages/times, response to interventions, disposition decision with rationale, and discharge instructions with follow-up plan. 1, 2

Core Documentation Components

Patient Identification and Chief Complaint

• Document patient identity including surname, forename, date of birth, and hospital unique identification number 3
• Record the chief complaint and history of present illness, as this drives the remainder of the examination and decision-making process 3
• Include time of symptom onset and any potential causes of the acute presentation 1

Clinical History Elements

• Medication history: Document all prescription medications, over-the-counter drugs, and herbal/alternative remedies with specific doses 1
• Allergies: Accurately document drug allergies including the specific reaction suffered, dose, and temporal relationship to the drug 1
• Previous healthcare utilization: Record number of previous ED visits, hospitalizations, and any episodes of serious complications (particularly intubation or ICU admissions) 1
• Current medications: List all medications and time of last dose, especially for condition-specific medications 1
• Chronic conditions: Document duration of chronic conditions, dates of diagnosis, and relevant comorbidities including cardiac, pulmonary, renal, psychiatric, and other systemic diseases 1, 3

Physical Examination and Severity Assessment

• Document objective findings that assess severity of the presenting condition, including level of alertness, respiratory distress, vital signs, and specific examination findings relevant to the chief complaint 1
• Use standardized severity classification systems when available (e.g., for asthma exacerbations, classify as moderate, severe, or life-threatening) 1
• Rule out complications and alternative diagnoses that could affect management 1

Time-Based Procedural Documentation

Medications and Interventions

• Create a time-based record documenting all drugs administered including name, dosage, route, and exact time given 1
• Document type and quantity of intravenous fluids administered 1
• Record whether oxygen was administered and the flow rate 1
• Document any reversal agents used (naloxone, flumazenil) as these patients require extended monitoring up to 2 hours 1

Serial Assessments

• Perform periodic assessments of level of consciousness, pain level (using a standardized pain scale), and vital signs at regular intervals 1
• For conditions requiring objective monitoring (e.g., asthma), document serial measurements of lung function (FEV₁ or PEF) at presentation and 30-60 minutes after initial treatment 1
• Record patient's response to treatment and any clinical deterioration 1

Disposition and Discharge Documentation

Decision-Making Rationale

• Document the clinical reasoning behind admission versus discharge decisions, including risk stratification 1, 4
• For patients being discharged, use standardized discharge criteria (such as Aldrete scoring system evaluating respiration, oxygen saturation, blood pressure, consciousness, and activity) 1
• Document that vital signs and clinical parameters have returned to baseline before discharge 1

Discharge Instructions and Follow-Up

• Provide both verbal and written instructions outlining diet, activity, medications, and follow-up evaluation 1
• Include an "action plan" for symptom recurrence with specific instructions on when to return to the ED 1
• Document a 24-hour contact person and telephone number for complications 1
• Confirm a responsible individual will accompany the patient home 1
• Clearly document any information provided to the patient in the clinical record to facilitate supporting advice from other healthcare professionals 1

Critical Administrative Elements

Coding and Billing Documentation

• Use ICD codes to document primary and secondary diagnoses, which is essential for determining principal discharge diagnoses 5
• Document procedure codes for any interventions performed, as this is crucial for hospital reimbursement and resource utilization tracking 5
• Include appropriate provider type codes to identify the consulting physician 5

Communication and Handoffs

• Document direct communication with the patient's primary care provider or referring physician about the consultation findings and management plan 6
• For patients with complex needs, document any social work referrals made for practical barriers (transportation, housing) or psychosocial issues (psychiatric history, substance use) 6
• Include information about who the patient can contact in case of emergency 6

Documentation Best Practices and Pitfalls

Efficient Documentation Techniques

• Use standardized forms that conform to institutional policies, as implementation of structured forms improves compliance with documentation and reduces sedation-related adverse events 1
• Employ one-click templates and macros for normal physical examination findings or review of systems, as these replicate what would be handwritten and are acceptable if the final signed documentation accurately reflects the encounter 1
• Include the patient's narrative in sufficient detail to accurately represent their story 3

Common Pitfalls to Avoid

• Avoid excessive copy/paste: Do not copy entire notes without editing, as this propagates factual errors, outdated information, and contradictory data 1, 3
• Avoid documentation cloning: Each entry should not be worded exactly like previous entries, as this is considered misrepresentation of medical necessity 1
• Avoid over-reliance on templates: Excessive use of drop-down lists and check boxes can be distracting and undermine clinical thinking, standardizing away the heterogeneity that makes each encounter unique 1
• Ensure accuracy over speed: The mental activity of converting patient narratives into coded values on highly structured screens can lead to errors 1

Quality and Safety Considerations

• Document any adverse events or near-misses that occurred during the consultation 1
• For high-risk patients (those with previous severe exacerbations, multiple recent ED visits, or significant comorbidities), explicitly document risk factors and heightened monitoring plans 1
• Ensure documentation captures data for appropriate standardized quality measurements 5