PREFORMATTED CHARTS IMPROVE DOCUMENTATION IN THE EMERGENCY DEPARTMENT

Study objectives: To determine if the use of programmed charts with complaint-specific entry criteria results in improved documentation of patient encounters and better clinical outcome. Design: Prospective study. Setting: Emergency department of an urban university hospital. Type of participants: Female patients presenting to the emergency department with gynecologic complaints of abdominal pain, bleeding, or vaginal discharge. Interventions: Programmed and blank charts were provided randomly for physicians in the ED. Measurements: Chart scores based on documentation criteria for patient history, physical examination, laboratory studies, diagnosis, and discharge instructions and patient outcome scores of 0% to 100% based on the persistence of their complaints at the time of the follow-up interview. Main results: Overall documentation of history, physical examination, and laboratory studies was more complete on programmed charts than on blank charts (81.1 % vs 71%, P < .0001). The patient history portion of the charts was found to benefit the most from the use of programmed charts (74.8% vs 60.1 %, P < .0001). Although programmed charts demonstrated better documentation, there was no statistically significant correlation with patient outcome parameters or with patient satisfaction with the quality of medical care. However, more patients whose physicians used programmed charts were satisfied with their physicians' explanations of their problem (chi-2 = 5.2, P < .02). Conclusion: Programmed charts improve documentation by facilitation of the documentation process and allow more time for patient-physician interaction. Quality of documentation alone, however, is not a reliable indicator of patient outcome or of the quality of care received.