Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey

OBJECTIVES

To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum.

METHODS

A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors prevalidated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons.

RESULTS

Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters are most frequently documented on free-form handwritten charts (38%), and a total of 76% of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent "never" record their supervising faculty's involvement in patient care, and another 25% record that information "1-25%" of the time. Seventy-nine percent are "never" or "rarely" requested by their faculty to clarify or add to medical records for billing purposes. Only 4% of the EM residents were "extremely confident" in their ability to perform billing and coding, and more than 80% reported not knowing the physician charges for services or procedures performed in the ED.

CONCLUSIONS

The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to overestimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED.

Test ordering guidelines can alter ordering patterns in an academic emergency department

To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. No restrictions were placed on actual test ordering. The number of laboratory tests (total and individual) ordered per 100 patients decreased significantly after the educational program began for: total testing, CBC, and liver function test (LFT). In addition, declines during individual months for these tests were statistically significant. Prothrombin time and blood culture testing showed no significant decreases in test ordering frequency. Chemistry test ordering frequency showed statistically significant increases. Overall, approximately $50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.

Interobserver variability among faculty in evaluations of residents' clinical skills

OBJECTIVE

To describe interobserver variability among emergency medicine (EM) faculty when using global assessment (GA) rating scales and performance-based criterion (PBC) checklists to evaluate EM residents' clinical skills during standardized patient (SP) encounters.

METHODS

Six EM residents were videotaped during encounters with SPs and subsequently evaluated by 38 EM faculty at four EM residency sites. There were two encounters in which a single SP presented with headache, two in which a second SP presented with chest pain, and two in which a third SP presented with abdominal pain, resulting in two parallel sets of three. Faculty used GA rating scales to evaluate history taking, physical examination, and interpersonal skills for the initial set of three cases. Each encounter in the second set was evaluated with complaint-specific PBC checklists developed by SAEM's National Consensus Group on Clinical Skills Task Force.

RESULTS

Standard deviations, computed for each score distribution, were generally similar across evaluation methods. None of the distributions deviated significantly from that of a Gaussian distribution, as indicated by the Kolmogorov-Smirnov goodness-of-fit test. On PBC checklists, 80% agreement among faculty observers was found for 74% of chest pain, 45% of headache, and 30% of abdominal pain items.

CONCLUSIONS

When EM faculty evaluate clinical performance of EM residents during videotaped SP encounters, interobserver variabilities are similar, whether a PBC checklist or a GA rating scale is used.

Frequent ED users: patterns of use over time

The objective of this study was to examine the pattern of emergency department (ED) use by frequent ED users over time. This study was a retrospective study of adults with more than 10 visits to a university hospital ED from 8/90 through 7/91. ED visits of this cohort to all hospitals in the metropolitan area were followed for 3 years. Records were reviewed for the etiology of each patient's ED visits. This cohort was comprised of 76 patients making 1,119 (1.9%) of the total 59,051 ED visits. Thirty-five of the 76 (46%) were frequent ED users in only the initial year. Thirteen of the 76 (17%) made more than 10 visits in all 4 years. The remainder had sporadic episodes of ED use. Thirty-five (46%) were evaluated at three or more EDs in years in which they were frequent users. Forty-two (55%) had a medical problem for the cause of the majority of their ED visits. Fifty-eight percent of patients making more than 10 visits in more than 1 year had psychiatric or substance abuse problems. The pattern of ED use in this cohort changed over time and was influenced by substance abuse and psychiatric problems. These data suggest that most patients do not remain frequent ED users over time.

Multiple cranial nerve deficits after ethylene glycol poisoning

We report the cases of two patients who developed cranial nerve palsies after drinking ethylene glycol. A 33-year-old man developed multiple cranial nerve deficits nine days after the ingestion of ethylene glycol in a suicide attempt. Clinical findings included profound bilateral cranial nerve VII palsies and severe dysfunction of cranial nerves IX and X. The neuropathy occurred despite treatment with hemodialysis. The dysphagia completely cleared within two weeks, but at six months a severe bilateral cranial nerve VII dysfunction persisted. A 22-year-old man undergoing hemodialysis for ethylene glycol-induced renal failure developed bilateral cranial nerve VII dysfunction 14 days after ingestion. At a three-month follow-up, the patient demonstrated only moderate functional recovery. The etiology of the cranial nerve deficits is unknown but may be related to oxalate crystal deposition of ethylene glycol-induced pyridoxine dysfunction.