Documentation in the pediatric emergency department: a review of resuscitation cases.

STUDY OBJECTIVE

Documentation practices of staff physicians, residents, and nurses managing critically ill children were reviewed for completion of standard documentation requirements.

DESIGN

Retrospective chart review.

SETTING

Municipal children's hospital.

PARTICIPANTS

144 patients treated in the cardiopulmonary/trauma resuscitation room over a 17-month period.

INTERVENTION

Emergency department records of these patients were reviewed for medical information required by Joint Commission on Accreditation of Healthcare Organizations guidelines: history of present illness, medical history, vital signs, physical examination, laboratory results, clinical observations, and diagnostic impression. In addition, the frequency of medical record review by legal representatives of the patient and by the state's social service agencies was evaluated.

RESULTS

Attending physicians demonstrated more complete documentation than residents in clinical observations of patients (36.4% vs 18.0%, P less than .005) and diagnostic impression (97% vs. 78.4%, P less than .03). Nurses demonstrated more complete documentation than physicians, as a group, in laboratory results (83.9% vs 47.6%, P less than .001) and clinical observations (80.6% vs 22.2%, P less than .001). Sixty-six medical records (37.9%) were subjected to legal review: 37 (21.3%) by patients' legal representatives, and 29 (16.7%) by the state's social service agency.

CONCLUSION

ED record documentation of pediatric patients treated in a cardiopulmonary/trauma resuscitation room often does not meet standard guidelines. Complete documentation is important due to the frequency of legal review of these records and the need to ensure post-ED continuity of care.