Template Explanation

Now that we’ve had a basic introduction to the documentation template, we’ll go through each section to illustrate some details and explain the importance. If you want to go back and review the template overview, click here. Lets jump right in:

The first section is a simple introduction to the patient and their presentation to the ED. This is what you would say if you were asked to summarize the situation in 1-2 sentences. But really try for just one sentence. It should fit in a tweet. But not a 280-character tweet. An old school tweet. 160 characters.

It should only include the presenting information, not what you did in the ED. And it should only include the relevant findings. This is the info you’d get from the most ADHD ER doc you can imagine. It’s so brief and to the point it would give most internists hives. The medical decision making (MDM) part of your note shouldn’t contain a full rehash of the history or exam, but the few relevant points should be included here in the very first sentence. The beginning should be structured in the same way that the first sentence of a patient presentation on rounds should be structured: age, sex, chief complaint. The rest will vary based on the situation. Remember: brevity is key. I can’t believe I wrote so much to describe such a tiny section of your note.

The differential is the list of diseases or conditions your patient might have. It is probably the most important part of the note. This section demonstrates that you thought about all the really bad things that could be causing the patient’s symptoms. It is the logical foundation to justify your testing, treatment, and overall management of the patient. The importance of the differential is illustrated when a medical student jumps straight from the H&P to the plan. Without an understanding of the differential, there is no logical way to organize a plan or approach to testing or treating the patient. The student must explicitly discuss the differential because the plan follows directly from the differential. Without a differential we are just monkeys randomly ordering tests. The differential drives many of the things we do in EM, although part of the fun of being an EM resident is that we often must take action without having finalized a differential let alone a diagnosis. The judge and jury looking at this case multiple years from now cannot read your mind, you must explicitly describe what you are thinking if you want to have a defensible chart.

There are some general rules when documenting your differential. I suggest that you include a minimum of 3 emergency diagnoses in your differential. A differential of one item is a recipe for disaster. This is often a challenge for learners who are new to medicine, and so I have made a list of cognitive tips to help improve your differential:

This section is unfortunately not done once you reach this point. It will need to be revisited later. After you have the results of testing and response to therapy, you will be ready to narrow the differential. Or admit that you cannot narrow the differential. In EM, knowing when you cannot narrow the differential is just as important as knowing when you can narrow the differential.

This section of the template helps reveal the thought process for the testing that you have ordered. Now that a differential has been constructed, you can use testing to help determine the likelihood of each of the items. Some of the testing you decide on is fairly obvious, especially to another physician or an expert witness reviewing your chart. The testing that is fairly obvious likely does not need much explanation. For example, if you suspect that the patient has severe anemia, checking a hemoglobin will be necessary and doesn’t really require explanation. Its obvious.

There may be other testing that is less obvious to someone else reading your chart, and the reason that you ordered these tests should be briefly described. A simple trick to make this section easier is to pair up every test that you have ordered with a disease process on the differential diagnosis. This level of detail is not required for every chart, but it is a useful exercise if you are having trouble figuring out what to write to satisfy this part of the template. Another useful tip is to use this section to explain why you didn’t order testing that other EM doctors may have ordered (even if you disagree with their rationale). Imagine a patient with shortness of breath, in which you thought about pulmonary embolism and included it in your differential but have ruled it out based on history, exam, risk stratification and PERC. You could then include a phrase that based on this assessment, you do NOT think that D-dimer or CT scan is indicated. Justifying why you DIDN’T do various tests can be just as important as justifying why you DID do certain tests.

Another useful point as illustrated in the PE example above is that not all tests involve blood draws or imaging. In fact, the most useful test we often have at our disposal is a good history. The physical exam may also be useful in very focused instances (or it may not be… debunking many aspects of the physical exam and exposing its futility in many cases could provide enough research content to fund an entire department of full professors. But I digress). With a very long and thorough differential, many of the items will likely be ruled out by history and exam alone. In fact, a thorough history and exam are usually sufficient to rule out all but 2-3 items on the differential. A simple sentence can be used to describe these items: “Based on the history and examination, I feel that the likelihood of DIAGNOSIS is so low that no further testing in this regard is warranted”. For the remaining items on the differential not ruled out by history/exam, labs, imaging, EKG, etc… will be used to help further narrow the differential.

Almost all patients in the ED are given some sort of treatment. This often occurs before the final diagnosis is made or before all emergencies have been ruled out. It can be something as simple as 600mg ibuprofen, or may consist of life-saving intervention that happen the second the patient arrives in the ED. The reason for most interventions is fairly obvious. If a patient is in pain, some type of analgesic may be offered. If the patient is nauseated, they will likely be given an anti-emetic. If they seems dehydrated, they may be given PO or IV hydration. Any treatment that deviates from the expected normal course should be documented and explained. Selection of treatment is often fairly self-evident, and the more relevant part to document is usually the response to the treatment.

Documenting the response to the treatment you have given is important. The response you are monitoring for varies widely by treatment type. Some of these are highly subjective, such as pain level or intensity of anxiety. There are also some responses that are objective. Did the patient’s heart rate improve after being given IV fluids? It may be difficult to establish a cause/effect relationship between treatment and outcome, but it is important to at least record any correlation. If you are proposing a particular diagnosis, then the known treatments for this disease should provide some improvement. It is a red flag if you diagnose a patient with a condition but the treatment is not providing any improvement within a reasonable timeframe. The reasonable time frame varies widely by disease and treatment. Giving antibiotics for cellulitis is unlikely to cause any improvement in erythema within the course of most ED stays (unless you’re in one of the unlucky EDs that board patients > 24 hours). Giving fluids to someone who is dehydrated and tachycardic would be expected to lower their heart rate within the course of a normal ED visit. While documenting subjective improvement in a patient’s symptoms is useful, documenting objective vital sign changes is even more important.

Once we have all of the results of the tests we have ordered, we now must interpret the results. This is where the line between the “testing” and “differential” parts of the template begin to blur, as they intersect each other. You should show how the results of these tests further rule out (or in) items on your differential. The best way to do this is to briefly comment on the results of the tests, using your own writing/interpretation. There is no need to hand-copy the results into your MDM, but you should comment and interpret. Simply commenting “Potassium is 6.9” has minimal utility (its already shown in the results section), but commenting “Patient is hyperkalemic and therefore was treated with XYZ” shows that you saw the results, understood its significance and reacted appropriately to address it.  

Please, for goodness sakes, do NOT copy/paste or autopopulate any results into your MDM. This is one of my biggest pet peeves. This applies to lab results, radiology interpretations, etc… Never in the history of medicine has copy/pasting the “results” section into the MDM section been helpful to anyone. The fact that you have copy/pasted or autopopulated the results into your MDM does not, in any way, indicate that you have actually looked at the results or interpreted them. It does not show any thought nor prove you actually looked at anything. Autopopulating results only proves that you have autopopulated results, not that you actually looked at them. It proves you like wasting space. It is extremely obvious when doctors do this, both to other medical providers and for lawyers/jurors/expert witnesses reviewing your chart later.  The information contained when you copy/paste testing results is freely and easily available in other parts of the documentation, there is no point in duplicating it.

Another point concerns pre-written phrases such as “I have reviewed all lab and imaging results and noted all abnormalities”, which are similarly useless. Pasting that phrase into your chart with a shorthand doesn’t actually show or prove that you did what it says. It is far better to just simply comment on the results that are relevant to you, and specifically show how you are synthesizing the results into a coherent clinical picture.

Finally, any significant abnormal findings should be commented on. Obviously, things that are rarely relevant to EM (for example, a mean corpuscular hemoglobin concentration that is a tiny bit outside the normal range) do not need to be commented on. But things that are significant should be commented on. Sometimes a result may actually add a disease to the differential or necessite further testing or treatment. Incidental findings that are non-emergent (usually found on imaging results; such as lung nodules) may not alter the differential during the current ED visit, but need to be communicated to the patient, and that communication needs to be documented.

Your documentation should address any discrepancies between your note and other people’s notes. The main sources of discrepancies are usually nursing notes or EMS notes. Anytime two people witness or are involved in an event, there will be slight differences in their recollection. This is just the simple nature of human memory; it is imperfect. Unfortunately, plaintiff’s attorney’s are fond of pointing out discrepancies in an attempt to discredit your documentation and your trustworthiness. Any large discrepancies must be addressed, but it is also useful to make sure that any small discrepancies are avoided.  These are best handled in a professional manner at the point of documentation. Most ED physicians, nurses, EMTs have a wonderful relationship and I would encourage to approach this issue in a way that will preserve a collegial working environment. If it is not possible, any large discrepancies should be explicitly noted and addressed.

There will be significant overlap here between the initial differential section, testing, and treatment. This is where the final synthesis of all of the information occurs. In this section you should make sure that all the emergencies considered in the initial differential have been shown to be so unlikely that no further testing is needed. Alternatively, you may have actually uncovered an emergency diagnosis, in which case this should be clearly stated. Remember, in EM, we do not necessarily need to make a diagnosis. We simply need to rule out emergencies. Do not feel obligated to arrive at one final diagnosis. If no emergencies are found, the patient should simply be given a symptom-based diagnosis (nausea, abdominal pain, chest pain, etc…). In cases where you strongly suspect a non-emergency diagnosis, it is best to indicate that while you suspect it to be the case, they will need to follow-up with their doctor for final confirmation.

When admitting patients, it is best to indicate who they are being admitted to and what time their care was handed over to the inpatient team. The transition to inpatient care is much more straightforward than discharging a patient, which is fraught with opportunities for failure. When being discharged, there are 3 important things that must be addressed to show that you safely discharged them.

    1. Treatment Plan

    2. Follow-up

    3. Return Precautions

Each of these 3 areas should include specific timing instructions. The first is the treatment plan. What should the patient be doing at home to help manage their symptoms and treat their condition? A pain plan is often a part of this. Any medications you prescribe should be part of this. If you recommend using hot/cold packs, it should be included. They need to know what they should be doing at home and how often (timing of instructions are critical). The next part is the follow-up. Most patients will need to have a follow-up with their primary care doctor. They need to be told, specifically, how many days until they should follow-up. Ideally all patients could get follow-up the next day, but this is usually not possible, so make a reasonable guess. Usually 2-5 days is a reasonable approach. They need to be told specifically who to follow-up with. This is probably their primary care doctor, but if you can get subspecialty follow-up and it is appropriate, it should be mentioned. The patient should also know how this will be arranged. Should they call their primary doctor? Should they wait for a phone call from an orthopedic clinic? What should they do if they don’t get a phone call? Finally, the patient needs to be given return precautions. Return precautions are instructions for returning to the ED. They should usually be tailored to the patients symptoms or disease process. Sometimes we know specifically what to watch out for. Other times, its useful to include general precautions, including a vague statement about returning “if you develop any new or worrisome symptoms”. As with all aspects of aftercare, the patient needs to know, specifically, when to return to the ED. And the answer (at least, the defensible answer) is pretty much always to return immediately to the ED if your condition worsens. Many EDs use pre-written discharge instructions that are given to patients, which are generally helpful, but it is even more protective if you both give them and document the information described above.

Hopefully this description of the Template will help you use it effectively on your next shift.