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*[[Against medical advice]]
==Background==
*[[Billing]]
*Thorough documentation is essential for patient safety, medicolegal protection, and appropriate reimbursement
*[[Critical care documentation]]
*The ED medical record serves as a legal document, communication tool, and billing justification
*[[Differential diagnosis documentation]]
*Poor documentation is the most common reason for malpractice verdict against the physician, even when clinical care was appropriate<ref>Self TH, et al. The importance of documentation in medical malpractice cases. J Pharm Pract. 2010;23(6):526-531.</ref>
*[[Procedure sample documentation]]
*Document in real time whenever possible; retrospective documentation is less accurate and less credible
*[[Reexamination sample documentation]]
*As of 2023, CMS E/M coding for ED visits is based primarily on medical decision making (MDM) or total time, no longer requiring specific history/exam element counts for billing level<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Other (Inpatient/Observation) Services Code and Guideline Changes. 2023.</ref>
*[[Observation documentation]]
 
*[[Physical exam documentation]]
==Key Principles==
*"If you didn't document it, it didn't happen" is not true, but is a standard medicolegal axiom
*Document
**The clinical reasoning, not just the diagnosis
**Discussions with patients, families, consultants, and PMDs
**Time-sensitive findings by time (e.g., time of stroke symptom onset, time antibiotics given in [[Sepsis|sepsis]])
**[[Against medical advice|AMA]] discussions thoroughly including capacity assessment
**Reassessments before [[Discharge documentation|disposition]]
 
==Components of the ED Medical Record==
 
===History===
*'''HPI''': location, severity, timing, modifying factors, associated symptoms, onset, quality, duration
*'''ROS''': see [[Review of systems documentation]]
*'''PMH/FH/SH''': past medical, surgical, family, and social history
 
===Physical Exam===
*See [[Physical exam documentation]]
*Tailor to chief complaint; document pertinent positives AND negatives
*Always document a reassessment exam prior to disposition
 
===Medical Decision Making (MDM)===
*See [[MDM for different chief complaints]]
*See [[MDM for different chief complaints (peds)]]
*MDM is the primary driver of billing level under current CMS guidelines
*Document differentials considered, data reviewed, and risk assessment
*See [[Differential diagnosis documentation]] for sample language
 
===Procedures===
*See [[Procedure sample documentation]]
*See [[Informed consent documentation]]
*Document: indication, consent, timeout, technique, findings, complications, post-procedure assessment
 
===Reassessment===
*See [[Reexamination sample documentation]]
*Document response to treatment, interval changes, and clinical trajectory
 
==Special Documentation==
*[[Critical care documentation]]: required for billing critical care time (CPT 99291/99292)
*[[Observation documentation]]: required for observation-status patients
*[[Against medical advice]]: capacity assessment and risk discussion
*[[Discharge documentation]]: discharge instructions, follow-up, return precautions
*[[Death documentation]]: time and pronouncement of death, family notification
*[[Informed consent documentation]]: procedural consent elements
 
==Billing==
*See [[Billing]] for detailed CMS requirements and RVU information
*MDM is the primary billing determinant for ED E/M visits
*Critical care time (≥30 min) is billed separately and often yields higher RVUs
*Document total critical care time and exclude separately billable procedures
 
==See Also==
*[[Residency: Basic Skills]]
 
{{Documentation pages}}
 
==References==
<references/>


[[Category:Documentation]]
[[Category:Documentation]]
[[Category:Misc/General]]

Revisión actual - 20:41 25 mar 2026

Background

  • Thorough documentation is essential for patient safety, medicolegal protection, and appropriate reimbursement
  • The ED medical record serves as a legal document, communication tool, and billing justification
  • Poor documentation is the most common reason for malpractice verdict against the physician, even when clinical care was appropriate[1]
  • Document in real time whenever possible; retrospective documentation is less accurate and less credible
  • As of 2023, CMS E/M coding for ED visits is based primarily on medical decision making (MDM) or total time, no longer requiring specific history/exam element counts for billing level[2]

Key Principles

  • "If you didn't document it, it didn't happen" is not true, but is a standard medicolegal axiom
  • Document
    • The clinical reasoning, not just the diagnosis
    • Discussions with patients, families, consultants, and PMDs
    • Time-sensitive findings by time (e.g., time of stroke symptom onset, time antibiotics given in sepsis)
    • AMA discussions thoroughly including capacity assessment
    • Reassessments before disposition

Components of the ED Medical Record

History

  • HPI: location, severity, timing, modifying factors, associated symptoms, onset, quality, duration
  • ROS: see Review of systems documentation
  • PMH/FH/SH: past medical, surgical, family, and social history

Physical Exam

  • See Physical exam documentation
  • Tailor to chief complaint; document pertinent positives AND negatives
  • Always document a reassessment exam prior to disposition

Medical Decision Making (MDM)

Procedures

Reassessment

Special Documentation

Billing

  • See Billing for detailed CMS requirements and RVU information
  • MDM is the primary billing determinant for ED E/M visits
  • Critical care time (≥30 min) is billed separately and often yields higher RVUs
  • Document total critical care time and exclude separately billable procedures

See Also

Documentation Pages

References

  1. ↑ Self TH, et al. The importance of documentation in medical malpractice cases. J Pharm Pract. 2010;23(6):526-531.
  2. ↑ American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Other (Inpatient/Observation) Services Code and Guideline Changes. 2023.
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