Documentation and The Emergency Department

Last Updated 11/11/01

AHA: Paperwork Time Rivals Patient Care
Every hour of patient care delivered can generate another 30 minutes to an hour of mandatory government paperwork for hospitals, researchers from PricewaterhouseCoopers concluded in "Patients or Paperwork?: The Regulatory Burden Facing America's Hospitals," a study commissioned by the American Hospital Association.
The Regulatory Burden Facing America's Hospitals (Adobe Acrobat file)

A Comprehensive Set of Coded Chief Complaints for the Emergency Department
Applying continuous quality improvement methods, the authors created a clinically developed and applicable set of codable chief complaints that can be easily integrated into a computerized patient record of an ED.

The Impact of Changes in HCFA Documentation Requirements on Academic Emergency Medicine
Link to an abstract: "The Health Care Financing Administration (HCFA) has dramatically increased documentation and procedural supervision required by faculty in academic emergency departments (EDs). Objectives: To determine academic emergency medicine (EM) physicians' perceptions of the impact of HCFA documentation requirements (HDR) on teaching time, clinical efficiency, and job satisfaction."

Voice recognition software versus a traditional transcription service for physician charting in the ED.
Link to a PubMed abstract: Am J Emerg Med 2001 Jul

With Hospitals at Risk From Faulty Documentation, Consider Tools for MDs

Electronic Paper & Pencil:
6 Easy Steps to a Low-Cost Electronic Medical Record
If you know how to use modern word-processing software,
you can create your own electronic medical records.

"My incomplete charting nearly did me in"
From Medical Economics: Sued because his documentation didn’t reflect the treatment he’d provided, the author was rescued by a surprise source.

Technology exam: Why should you buy?

Before prescribing technology for what ails your practice, diagnose the problems in your office and take the time to examine the most workable solution.

Patient care efficiency and medical error reduction using pda-based medical information

Work is minimized by taking full advantage of the PDA platform with a simple, fast, comprehensive interface. The main goal of this innovation is to improve the usefulness of medical information resources by maximizing relevance and validity, while reducing work.

Templates

ePowerDoc

"ePowerDoc is a unique, affordable documentation system that enhances patient care while simplifying the challenges of medical charting. Rich in content, ePowerDoc dramatically improves the physician’s ability to quickly and comprehensively capture the patient encounter.

Comprised of over one hundred complaint-specific templates, ePowerDoc is formatted to accommodate the way the physician thinks by following the natural and logical patient sequence.  Sophisticated yet simple,  ePowerDoc works as efficiently as the physician and produces a clear picture of the patient encounter.

Designed in form and content to satisfy the most seasoned physician, ePowerDoc templates also prompt the caregiver to easily record all the data required by HCFA for appropriate reimbursement.  And because documentation drives reimbursement, revenues are maximized.  Additionally, hospital administration is reassured, knowing that billing is accurate and documentation is complete."

The T-System

Workstation

Lynx Medical Systems

"LYNX provides documentation management and coding solutions designed to help you meet these challenges. Our software products and professional services are designed with the primary objective of helping establish a defensible coding process, which in turn minimizes compliance risk. LYNX solutions also help reduce costs, protect appropriate revenue, and enhance the clinical care process."

EmStat

"EmSTAT is the most widely used Emergency Department Information System among the top 1,000 hospitals in the country. Our customers benefit from reduced patient time in department, improved reimbursement, reduced risk and greater access to information for better decision making."

HEALTHMATICS ED

HEALTHMATICS ED utilizes drill-down navigation and voice, pen-based or touch-screen technology to perform all aspects of data management for the emergency department. The entire patient encounter is documented and managed on a system that supports concurrent staff and provider documentation in order to build a single, seamless patient record.

Meditech

MEDITECH's Emergency Department Management application assists Emergency Department clinicians and staff in the critical task of managing patients quickly and efficiently.

ER Records

"Your documentation is the only record of your Doctor-Patient relationship. That document should be a professional creation that illustrates medical investigation, procedural record, diagnostic acumen, highlighted with an overtone of human compassion. Unfortunately, in today's pressured healthcare environment, the humanistic flavor of that record is being lost to the outside pressures of bureaucratic business administration and Medical Jurisprudence. These influences are forcing the loss of a learned art. The art of Medicine, and the art of documentation. The only evidence of your medical acumen, diagnostic skills, and humanistic interactions is that found in the medical record. While the reality of today's changes warrant adaptation, this shouldn't be lost to a record of checks and slash marks. Your document should always maintain the quality of a............................ Narrative Portrait!"

Web-Based

Medscape Encounter

PulseCheck

PulseCheck® Physician Documentation System is an intuitive software solution that allows physicians to easily document each patient encounter using templates and/or voice dictation. Templates are organized by "chief complaint" and can be filled out quickly and easily on a desktop or laptop computer, or on a pen computer on a wireless radio frequency network.

Templates and Web-Based

nuMedica

Palm Pilot

Digital Assist - ER

We've downloaded the demo version of this ED Charting software and it looks very promising. The Palm OS program leads the user from patient information, through chief complaint, and a customized examination that includes HPI and ROS. 
The chart automatically prints when you  hot sync the Palm. 

They have aspirations for porting the same system to ER Nursing and Homecare.

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