What is the appropriate medical decision making template for an Emergency Room (ER) visit?

From the Guidelines

A comprehensive medical decision making template for an emergency room visit should prioritize the patient's presenting problem, including severity and acuity level, and document all diagnostic data reviewed, as well as the interpretation of these results and how they influenced clinical reasoning, as recommended by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction 1. When creating a medical decision making template for an ER visit, several key components should be included to ensure thorough documentation.

• Begin with a clear assessment of the patient's presenting problem, including severity and acuity level.
• Document all diagnostic data reviewed, including laboratory results, imaging studies, and any point-of-care testing performed.
• Include your interpretation of these results and how they influenced your clinical reasoning.
• Detail the number and complexity of diagnoses considered in your differential diagnosis.
• Document your risk assessment, including the risk of complications, morbidity, or mortality without treatment, as well as potential complications from treatments provided.
• Include your clinical judgment regarding the need for additional testing, consultation with specialists, or admission versus discharge.
• Document your medical decision making process regarding treatment options, including medications prescribed (with specific names, dosages, and durations), procedures performed, and patient education provided.
• Finally, include your disposition plan with clear follow-up instructions. This structured approach ensures that your medical decision making is thoroughly documented, which is essential for patient care continuity, medical-legal protection, and appropriate billing, as supported by the guidelines 1. The complexity of medical decision making (low, moderate, or high) is determined by the number of diagnoses considered, the amount of data reviewed, and the risk of complications, which directly impacts the level of service that can be billed, as noted in the 2011 ACCF/AHA focused update incorporated into the ACC/aha 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction 1. In the context of acute coronary syndrome (ACS), it is crucial to evaluate patients rapidly, as decisions made on the basis of the initial evaluation have substantial clinical and economic consequences, and patients with suspected ACS should be advised to chew ASA (162 to 325 mg) while awaiting arrival of prehospital EMS providers, as recommended by the guidelines 1. Additionally, prehospital EMS providers should perform and evaluate 12-lead ECGs in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions, as supported by the evidence 1. By following this template and prioritizing the patient's presenting problem, healthcare providers can ensure that their medical decision making is thorough, well-documented, and aligned with current guidelines and evidence-based practices, ultimately improving patient outcomes and reducing morbidity and mortality.

From the Research

Medical Decision Making Template for an ER Visit

• Patient Assessment: Evaluate the patient's condition and identify the chief complaint 2
• Diagnostic Considerations: Consider potential diagnoses and order relevant tests to confirm or rule out conditions 2
• Treatment Options: Develop a list of potential treatment options, including medications, procedures, and lifestyle changes 2, 3
• Shared Decision Making: Engage the patient in the decision-making process, discussing the risks and benefits of each treatment option and incorporating their preferences and values 4, 5
• Clinical Uncertainty: Recognize when there is clinical uncertainty or equipoise, and use shared decision making to involve the patient in the decision-making process 5
• Patient Decision-Making Ability: Assess the patient's capacity and willingness to participate in their emergency care decisions 5
• Time Constraints: Consider the acuity of the clinical situation and the time available for the shared decision-making conversation 5
• Medication Management: Consider the use of medications such as aspirin, nitroglycerin, and other therapies as recommended by guidelines 2, 3
• Procedure Considerations: Consider the need for procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) 2
• Follow-up Care: Develop a plan for follow-up care, including any necessary tests, treatments, or lifestyle changes 2

Key Considerations

• Acute Coronary Syndrome: Consider the diagnosis and management of acute coronary syndrome, including the use of aspirin, nitroglycerin, and other therapies 2, 3
• Patient Engagement: Engage the patient in the decision-making process, using shared decision making to promote active involvement in their care 4, 5
• Clinical Guidelines: Follow clinical guidelines and recommendations for the management of specific conditions, such as acute coronary syndrome 2
• Individualized Care: Provide individualized care, taking into account the patient's unique needs, preferences, and values 4, 5