Cole A B, Counselman F L
Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk.
Ann Emerg Med. 1995 Apr;25(4):445-50. doi: 10.1016/s0196-0644(95)70256-3.
To compare transcribed and handwritten emergency department charts for completeness of documentation.
Convenience sample, retrospective chart review.
Level I tertiary-care referral center and primary training site for a fully accredited postgraduate year 2 through postgraduate year 4 emergency medicine residency program.
Two hundred two patients admitted to telemetry or CCU/ICU with a final diagnosis of myocardial infarction, unstable angina, rule out myocardial infarction, or evaluation of chest pain from July 15, 1990, through June 30, 1991.
Each chart, unknown to the faculty and residents, was reviewed for documentation of the presence or absence of 28 critical items. Equal weight was given to each item. Two-tailed testing for independent proportions was used to determine the presence of a statistically significant difference between the transcribed and handwritten charts. In addition, the mean and SD for the number of critical items documented were determined for both the transcribed and handwritten charts. A two-tailed Student t test was used to determine the presence of a statistically significant difference. Significance was set at a P value of less than .05.
Ninety-four transcribed and 108 handwritten charts were reviewed. Transcribed charts contained a greater proportion of the 28 critical items than did the handwritten charts (P < .05). The mean number (19.6 +/- 4.0) of critical items present in the dictated charts was significantly greater than the mean number (15.8 +/- 4.0) of items present in the handwritten charts (P < .0001).
Transcribed ED charts contain more complete documentation than handwritten charts in the evaluation of patients who present with chest pain of suspected ischemic origin.
