Question

The Emergency Department Chair has asked for an audit of ED records in preparation for an upcoming Joint Commission survey. Your staff conducted the audit against the Joint Commission standard that addresses ED documentation. The results were very poor, with no consistency in documenting the required components. You check the medical staff by-laws and realize that there are no specifics related to ED documentation.

1. Determine the Joint Commission documentation requirements for Emergency Department reports. List them here.

2. Audit the five representative ED cases below to determine the major areas in need of documentation improvement. As HIM director, present your results in a short memo to the ED Department Chair, Dr. Wilkerson.

3. Create a new section for the medical staff by-laws that incorporates ED documentation requirements. Include this in the memo to the Chief of the ED for his approval before it continues through the formal process for inclusion into the by- laws.

4. The timing for this coincides with the transition of ED documentation into an electronic format. You propose to utilize the electronic record to facilitate the appropriate data collection. Create a screen design that encompasses the required ED documentation data elements.

   ER Report 1:

   HPI: Four year old female arrived after fall on trampoline. Patient fell and landed on her right elbow. Complaining of pain. Tearful.

   PMH: Child currently on antibiotics for an acute otitis media infection of her left ear. Tympanum still inflamed.

   IMMUNIZATIONS: Up-to-date.ALLERGIES: None known.PHYSICAL EXAMINATION:

   VITAL SIGNS: Temperature 36.8 Celsius, pulse 95, respirations 22, blood pressure 114/77, weight 18 kilograms.
   GENERAL: Alert, minimal distress upon palpation of elbow.
   SKIN: Negative

   HEENT: Head: Normal. Eyes: PERRL. Nose and throat normal. Ears: Left tympanum inflamed.
   NECK: Supple, no lymphadenopathy, no masses.
   LUNGS: Clear bilaterally.

   HEART: Normal S1, S2. Regular rate.
   ABDOMEN: Soft, non-tender. Bowel sounds are present. EXTREMITIES: Warm. Right elbow tender to palpation.

   NEUROLOGICAL: Alert.
   X-RAY: Right elbow shows supracondylar fracture.

   EMERGENCY ROOM COURSE: Patient had an x-ray of the right upper extremity which showed a displaced supracondylar fracture. A long arm splint was applied. No lab work was done.

   DX: Displaced, right supracondylar fracture.DISPOSITION: Home with parents.

   ER Report 2:
   CHIEF COMPLAINT: Ankle pain.

   HISTORY OF PRESENT ILLNESS: A 67-year-old female fell off a curb while crossing the street. Complains of pain in left ankle and right wrist, as she landed on the wrist when she fell. No other injuries are apparent.

   PMH: COPD. Hypertension. Diabetes. Smoker.
   PAST SURGICAL HISTORY: Appendectomy 10 years ago.SOCIAL HISTORY: Denies alcohol.
   ALLERGIES: NKDA.
   MEDICATIONS: Spiriva. Lisinopril. Humulin.
   ROS: Ten systems reviewed and negative unless noted above.

   PHYSICAL EXAMINATION:

   VITAL SIGNS: Temperature 98.7, pulse 81, respirations 19, blood pressure 130/83, and pulse oximetry 93 percent on room air.

   GENERAL: No acute distress.

   EXTREMITIES: Full range of motion in his right knee. Palpation of the ankle and Achilles tendon elicit no pain. Pulses are intact, with strong capillary refill. Normal sensation. There is pain on the lateral aspect of the right foot. Contusion and swelling noted as well. Dorsal foot pain present too.

   X-RAY: Left ankle shows lateral malleolus fracture. Right wrist film shows an intraarticular distal radius fracture.

   DX: Fractures of left ankle and right wrist as evidenced on x-rays. Contusion of lower left leg.DISPOSITION: Splints applied on both extremities (arm and leg) and prescription given for

   Motrin 800mg. to be taken four times a day. Home to follow with ortho tomorrow.

   ER Report 3:
   CHIEF COMPLAINT: Shortness of breath brings this 72-year-old Caucasian female to the

   ER transported by her husband.

   HPI: Patient is in ER often due to her COPD exacerbations. Today the patient experienced severe respiratory distress. Her husband states the patient was admitted two weeks ago with bronchial pneumonia and discharged last week. Patient continued to have a chronic cough after discharge and today all her symptoms worsened.

   PMH: Hypertension, emphysema, and lupus.
   MEDICATIONS: Dyazide, and Atrovent inhaler.
   ALLERGIES: NKDA.
   SOCIAL HISTORY: The patient is florist, married, with 2 children.REVIEW OF SYSTEMS: Ten system review normal except as noted above.

   PHYSICAL EXAMINATION:

   VITAL SIGNS: Temperature 101.3. Pulse 91. Respirations 22. Blood pressure 136/88. Initial oxygen saturations on room air are 84.
   GENERAL: Breathing is labored.
   HEENT: Head is normal.

   NECK: The neck is supple.
   LUNGS: Auscultation of the chest reveals faint breath sounds, on the right, no obvious rales. HEART: Sinus tachycardia.
   ABDOMEN: Nontender.
   Extremities: Slight pedal edema.

   DIAGNOSTIC DATA: White blood count 16.5, hemoglobin 15, hematocrit 41.3, Sodium of 137, chloride 80, CO2 45, BUN 7, creatinine 0.8, glucose 192, albumin 3.4 and globulin 4.0. Urinalysis normal.

   X-RAY: Early infiltrates noted on chest x-ray.

   EMERGENCY ROOM COURSE: One gram of Rocephin was administered intravenously as there is evidence that pneumonia is persisting. Further medication orders included Atrovent q. 2h. and Levaquin 500 mg IV. Patient appears to have a degree of respiratory failure and possible sepsis.

   28 Data Content, Structure, and StandardsFINAL DIAGNOSIS: Pneumonia.

   DISCHARGE INSTRUCTIONS: Patient admitted to medical floor. Will require close observation and care.

   ER Report 4:
   CHIEF COMPLAINT: Abdominal pain.

   HPI: This 58-year-old Caucasian complains of unrelenting right lower quadrant abdominal pain. Began in the early hours of the morning, actually awakening the patient from his sleep. Has not abated and patient decided to come to ER for evaluation.

   PMH: Healthy.
   REVIEW OF SYSTEMS: Nausea with one episode of emesis after arrival in ER.SOCIAL HISTORY: Married, no children.
   FAMILY HISTORY: Negative.
   MEDICATIONS: None.
   ALLERGIES: NKDA.

   PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.5, heart rate 95, blood pressure 125/76, respiratory rate 21. GENERAL: Patient in acute abdominal distress. HEENT: Unremarkable. NECK: Supple. LUNGS: Clear. CARDIAC: Slight tachycardia. ABDOMEN: Soft, tender at McBurney’s point.

   ED COURSE: Lab work done which resulted in elevated white count. Abdominal CT scan done which supported diagnosis of appendicitis.

   IMPRESSION: Acute appendicitis.
   ASSESSMENT AND PLAN: Admit patient and take to surgery for appendectomy. Surgeon

   on call notified of admission.

   ER Report 5:

   HPI: A 32-year-old black male arrived in the ER. He was incoherent and barely able to stand. Companion states he may have “gotten some bad drugs”. Companion indicates patient did heroin 45 minutes ago and had a bad reaction, so he brought him here.

   ALLERGIES: NKDA.
   MEDICATIONS: Unknown.
   PAST SURGICAL HISTORY: Unknown.
   FAMILY HISTORY: Unknown.
   SOCIAL HISTORY: Smokes, consumes 6 beers a day, uses street drugs.

   PHYSICAL EXAMINATION:

   VITAL SIGNS: temperature of 99.2 degrees, pulse 66, respiratory rate is 14, and blood pressure is 90/51, recheck blood pressure was 90/50.
   GENERAL: Disoriented.
   HEENT: Pupils dilated.

   NECK: Supple. CHEST: Clear.
   HEART: Regular. ABDOMEN: Soft. SKIN: Color is normal.

   EXTREMITIES: Laxity in all extremities. NEUROLOGIC: Decreased reflex responses.

   ER COURSE: Labs were drawn and IV fluids started. Narcan was administered and patient had good response. Patient admitted to ICU in critical condition.

   IMPRESSION: Heroin overdose.

Answer 1

1. List of Joint Commission documentation requirements

As per the Joint Commission Documentation, the Emergency department should report the following requirements,

• Time of arrival of the patient to the emergency department
• Condition of the patient, final disposition, discharge instructions.
• Document if Discharged against medical advice.
• Copy of follow-up by the physician.

2. Audit of five ER cases:

• time of arrival of the patient is not mentioned.
• Discharge report and follow up of physician is not mentioned.
• Document of Discharge treatment advice has to be improved.
• Condition at discharge has to be documented properly.