Presentation on theme: "Edward P. Sloan, MD, MPH ED Documentation: A Systematic Approach to the Care of Critically Ill Patients."— Presentation transcript:
Edward P. Sloan, MD, MPH ED Documentation: A Systematic Approach to the Care of Critically Ill Patients
Edward P. Sloan, MD, MPH ICEP Academic Forum ICEP Research Committee Northwestern University April 29, 2004
Edward P. Sloan, MD, MPH Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL
Edward P. Sloan, MD, MPH Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL
Edward P. Sloan, MD, MPH Global Objectives Maximize patient outcome Maximize patient outcome Enhance ED critical thinking Enhance ED critical thinking Provide a powerful record Provide a powerful record Optimize peace of mind Optimize peace of mind Improve clinical practice Improve clinical practice Increase career longevity Increase career longevity
Edward P. Sloan, MD, MPH Sessions Objectives Review critical care ED case Review critical care ED case Examine ED documentation Examine ED documentation Compare to consultants Compare to consultants Decide how to optimize our record keeping in the ED Decide how to optimize our record keeping in the ED Develop a specific plan Develop a specific plan
Edward P. Sloan, MD, MPH A Case: 22 yo Found Unconscious on the Floor
Edward P. Sloan, MD, MPH CFD History HR 90, RR 10 - Patient found unconscious on the floor, pants down around his knees…IV line, narcan, it took over two minutes for pt to become CAO x 3…transport…
Edward P. Sloan, MD, MPH RN Note - 140/ s º - No drugs - No chest pain - Pt has vials of white powder - Respirations unlabored - Patient says he feels fine
Edward P. Sloan, MD, MPH Attending Note 7:50 22 yo = CFD pt = AMS? Syncope? = Related to drug? = Pt denies all drug use = No trauma = No known etiology of syncope = No other complaints
Edward P. Sloan, MD, MPH Physical Exam = pt alert, NAD = VS Noted Inc HR, Dec O2 sat, No inc RR = No toxidrome evident = Head: pupils E/R EOM OK, airway OK = Neck: supple, no crep = Chest: ?clear, BSB=, few rhonchi = Cor: rapid without
Edward P. Sloan, MD, MPH Physical Exam = Abd: soft, NT = Ext: non-tender, no calf tenderness = Neuro: Appropriate MS, speech NOT post-ictal NO IVDA marks No tongue trauma = pulse ox 88% RA = pulse ox 88% RA
Edward P. Sloan, MD, MPH Sick? Not sick??
Edward P. Sloan, MD, MPH Workup??
Edward P. Sloan, MD, MPH Differential Diagnosis??
Edward P. Sloan, MD, MPH Problem List??
Edward P. Sloan, MD, MPH Problem List - Altered Mental status - R/o syncope - R/o seizure - R/o drug, EtOH ingestion - R/o trauma - R/o metabolic abnormality
Edward P. Sloan, MD, MPH Problem List - Tachycardia - R/o cardiac dysrhythmia - R/o dehydration - R/o drug, EtOH ingestion - R/o trauma, hemorrhagic shock - R/o metabolic abnormality
Edward P. Sloan, MD, MPH Problem List - Hypoxia - R/o cardiac etiology, ie CHF - R/o ARDS - R/o pneumonia - R/o PE - R/o bronchospasm
Edward P. Sloan, MD, MPH Problem List - Pants around the ankles - R/o …. - R/o “funny business of some sort”
Edward P. Sloan, MD, MPH The Upshot Your work is compelling So must be your documentation You do medical decision making You must document MDM All systems make this difficult You must, therefore, be systematic
Edward P. Sloan, MD, MPH Your ED Documentation Compelling Complete Systematic Involves data integration Provides accountability Improves care
Edward P. Sloan, MD, MPH Clinical Questions How did the patient present? What was your problem list? What was your Differential Dx? What work-up did you do? What Rx did you provide? What was your disposition? WHY?
Edward P. Sloan, MD, MPH How Did the Patient Present? Establishes baseline status Explains, in part, outcome Determines need for Rx Most important in critical illness This is your H & P Pain or respiratory distress
Edward P. Sloan, MD, MPH What Was Your Problem List? Respiratory distress Bronchospasm with hypoxia Bilateral pneumonia Altered mental status First diagnoses symptom-based
Edward P. Sloan, MD, MPH What Was the Differential Dx? Hypoxia due to: Bronchospasm Bronchopneumonia Pulmonary embolism Exacerbation COPD ARDS Toxic inhalation Determines ongoing therapies
Edward P. Sloan, MD, MPH What Work-up Did You Do? What tests? What results? What interpretation? What need for therapy? Interpret and treat, not annotate
Edward P. Sloan, MD, MPH What Rx Did You Provide? What therapies? What result? What response to therapy? Did the patient stabilize? What didn’t you do?
Edward P. Sloan, MD, MPH What Was Your Disposition? Who did you talk to? Where did your patient go? What was the expected outcome? What was the patient’s status? Who knew what? Agreement?
Edward P. Sloan, MD, MPHWhy? Why did you do what you did? What was clinically indicated? What patient preference? What opportunities to maximize patient outcome were provided? What uncertainty? What decisions given uncertainty?
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Medical Decision-Making Problem List Differential Diagnosis ED Therapies Provided ED Testing Provided Response to Therapy Repeat Exam
Edward P. Sloan, MD, MPH Medical Decision-Making Consultations Provided Disposition Patient Status at Disposition ED Diagnoses Follow-up Discharge medications Patient/Family Understanding
Edward P. Sloan, MD, MPH Our Consultants Stop and look at big picture Consider all possibilities Look forward at next steps More of a medicine approach Completeness; More R/o Dx Not necessarily better per se Consultants look “smarter”
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Consultants: MDM Learning Step back and think like one Put your thoughts on paper Include plenty of R/o s Think like “the other guy” Initiate ongoing therapies Make it easy to transfer care List every possible Dx
Edward P. Sloan, MD, MPH Optimizing ED Documentation Develop a systematic process Follow rigid principles Treat variance as an exception Continue to reassess the process
Edward P. Sloan, MD, MPH A Specific Process Part 1: Assess the pt, problem Part 2: Treat, assess response Part 3: Summarize, disposition Do it all over again
Edward P. Sloan, MD, MPH Part 1: Assess Pt, Problem Read the triage note Go to the bedside Write a note Go to the computer Develop a differential Consider options
Edward P. Sloan, MD, MPH Part 2: Treat, Reassess Treat the patient Interpret the results Reassess the patient Obtain consultations Document the results
Edward P. Sloan, MD, MPH Part 3: Summarize, Dispo Complete the problem list Assess remaining issues Document status, likely outcome Identify relevant W’s
Edward P. Sloan, MD, MPH Optimizing ED Care & MDM Write to think Medical record: working document Use multiple sheets of paper Don’t scribble Write your problem list early Complete medical decision making Allow your writing to influence you
Edward P. Sloan, MD, MPH Optimizing ED Care & MDM Document change in status or plan Pretend you are the consultant Disposition with multiple diagnoses Write as you talk Write as you assess Write as you interpret Write as you think
Edward P. Sloan, MD, MPH ED MDM Principles Everything good happens at the patient bedside Give no advice without seeing the patient Make no decisions without writing in the medical record Act not on what the problem likely is, but what it could be
Edward P. Sloan, MD, MPH ED MDM Principles Be a problem solver Personalize the approach Be systematic Assess risk Make decisions Document why decisions are made First do no harm
Edward P. Sloan, MD, MPH Your Specific ED Plan Know your own style Know what options exist Plan to enhance document Utilize paper Consider preformatted sheets Consider dictation
Edward P. Sloan, MD, MPH Documenting MDM Pen and paper is best Dictate only your H and P Write medical decision making Know when each gets to the chart Know when discrepancies exist Careful not to over-include data
Edward P. Sloan, MD, MPH The T-System Quick and efficient Limited writing Limited medical decision making Why did you do what you did? What do others need to know? Who knew what when? Why?
Edward P. Sloan, MD, MPH The Retrospective Look The chart will have scribbles Some things will be missing MDM will be unsubstantiated Consults will be under-documented Awareness will be rarely listed Deposition: what were you thinking?
Edward P. Sloan, MD, MPH Retrospective Perspective Does it matter? Yes Must you strive for perfection? Yes Will you achieve perfection? No Can you do more than develop a system for minimizing errors? No Do your best, forget the rest!
Edward P. Sloan, MD, MPH Medical Decision-Making Problem List Altered Mental Status Hypoxia Tachycardia R/o syncope R/o toxic inhalation R/o BHT/TIA/CVA/Sz R/o ARDS, pneumonia
Edward P. Sloan, MD, MPH Medical Decision-Making Differential Diagnosis (see above) ED Therapies Provided O2, albuterol, fluid bolus Lovenox, antibiotics ED Testing Provided EKG, CXR, CT, ABG, Labs Interpretations Hypoxia, hypercarbia, tachycardiaa
Edward P. Sloan, MD, MPH Medical Decision-Making Response to Therapy Pt still tachycardic No respiratory distress Mental status improved Repeat Exam Lungs BSBE with wheezes No focal neurologic findings
Edward P. Sloan, MD, MPH Medical Decision-Making Consultations Provided ID: levoquin added Pulmonary: start lovenox Disposition Admitted to ICU Patient Status at Disposition Stable, but still tachycardic, MS ok
Edward P. Sloan, MD, MPH Medical Decision-Making Discharge medications Further Rx per PMD, consultants Patient/Family Understanding Patient and family aware of clinical status and need for ICU care Critical care time of 45 minutes
Edward P. Sloan, MD, MPH Medical Decision-Making ED Diagnoses Altered mental status Hypoxia due to bronchospasm Likely pulmonary embolism Bilateral pneumonia vs ARDS R/o toxic ingestion/inhalation
Edward P. Sloan, MD, MPH Some MDM Chart Examples PMD notified, cards prn CT NCI, deferred by pt, family Ongoing therapy per cards Pt critically ill, but stable Family aware of critical illness and likely demise Further Rx deferred, DNR signed
Edward P. Sloan, MD, MPH Some MDM Chart Examples Patient defers admit x2 NCI Pt defers admit, despite need Close follow-up with PMD Pt, PMD aware of plans
Edward P. Sloan, MD, MPH Some MDM Chart Examples Out AMA Pt wants to see PMD in AM Aware of risks including death Judgment not clinically impaired All optimal therapies provided May return at any time High risk symptoms explained
Edward P. Sloan, MD, MPHConclusions Documentation is everything Extemporaneous info is king Develop a system Be systematic Do it real-time Be comfortable with writing Let the process guide your thinking
Edward P. Sloan, MD, MPH Questions? icep academic forum criticalcaredoc show.PPT