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 less than .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 less than .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 less than .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.