Documentation for emergency physicians

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
• 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

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)

• 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

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations