Charting Methods: Each Has Legal Pros and Cons
If time wasn't a factor and if charting were an enjoyable activity, emergency physicians (EPs) would presumably always produce thorough, accurate documentation a key factor in minimizing legal risks.
"No method of charting is much fun, and time is always short," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL. "It behooves hospitals to provide a system that produces efficient, accurate, and robust charting." Here are some of the legal advantages and disadvantages for the most common charting methods, according to Scaletta:
Handwritten charting
"This is often indecipherable, and corrections may appear suspicious in the courtroom," says Scaletta. "Other medical providers need to muddle through the scribble to know what happened." Since handwritten charts require scanning, he adds, they could be lost more easily than electronic versions.
Voice-activated dictation
"This is certainly not as fast as transcription, from the EP's perspective," says Scaletta. "It requires a careful read-through, so the kind of gibberish that you would not want to see in a courtroom exhibit is not overlooked."
Editable templates
These may not reflect what actually happened when a non-standard approach is taken. "They do not personalize the story," says Scaletta. "Every case tends to look the same, so you cannot keep patients with the same complaint sorted out as easily."
However, Scaletta says that templates are a time-efficient means of creating the standard portions of the chart, including procedure documentation.
"ED information systems that incorporate exclusively template-driven charting are cumbersome, resulting in less time at the bedside," says Scaletta. "On the flip side, they can offer some useful decision support and improve safety."
Scribes
There are financial costs to providing assistance with transcription, acknowledges Scaletta, "but it may be even more costly to skimp on this because of resultant lost revenue and increased claims." However, scribed charts require careful editing to be sure the verbatim history paints the correct picture.
"For instance, the word 'dizzy,' in my opinion, should not appear in a history," he says. "It really needs to be clarified as a layperson relaying lightheadedness, vertigo, altered sensorium, or something else entirely."
Scribes may neglect to record information shared by a patient, adds Scaletta, or act in a manner beyond their scope by interpreting what they believe the patient or doctor meant to say.
"Some EPs use scribes to document by exception 'Use my normal [pulmonary embolism], except if there are crackles in the left lung base.' This could lead to inadvertently documenting a portion of the exam as normal, when it was not examined," he says.
Dictation/human transcription
This is the most expensive charting method, says Scaletta, but it achieves the highest quality for the open-ended portions of documentation, including the history of present illness, medical decision-making, and discussions with other physicians or the patient.
"Free-form documentation requires good storytelling," says Scaletta. "EPs generally are experts in gaining someone's confidence and trust in a matter of seconds, and condensing several days of events in a matter of minutes."
The ideal charting strategy is a hybrid of dictation, human transcription, and editable templates, says Scaletta, such as using a high-quality automated emergency department information system, designing editable templates for standard documentation, and dropping voice clips into the open-ended portions of documentation.
"Have a capable transcriptionist convert the voice clips, look over the final product, and relay concerns to the EP before the documentation is etched in stone," he advises.
Source
For more information, contact:
Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, Il. Phone: (630) 527-5025. E-mail: [email protected].
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