Where's the Beef? The Promise and the Reality of Clinical Documentation

Abstract

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.

Incidence of speech recognition errors in the emergency department

“…Errors in medical documentation are a critical problem that can adversely impact quality of care and patient safety (11)(12)(13)(14)(15). We found nearly 71% of notes contained errors with an average of 1.3 errors per note.…”

Improving documentation of procedural sedation in an adult emergency department

“…These risks and the discharge advice and information given need to be documented in case of later legal argument. (2) Lack of documented information, especially regarding depth of sedation achieved or adverse reactions during the procedure, may impact on patient safety during future similar episodes [13]. (3) Preprocedural anesthetic and airway risk assessment improves the safety of the procedure.…”

Quality management and benchmarking in emergency medicine

“…In addition, adequate clinical documentation serves a few more purposes, including recording of medical care and communication among providers; payment for hospital and physician; legal defence from medical negligence allegations; and symptom/disease surveillance, public health, and research [30].…”