Prospective, Randomized Trial of Template-assisted Versus Undirected Written Recording of Physician Records in the Emergency Department

doi:10.1016/S0196-0644(99)70336-7

Annals of Emergency Medicine

Volume 33, Issue 5, May 1999, Pages 500-509

Presented at the Texas College of Emergency Physicians Annual Meeting, Galveston, TX, April 1998, and the Society for Academic Emergency Medicine Annual Meeting, Chicago, IL, May 1998.

https://doi.org/10.1016/S0196-0644(99)70336-7 Get rights and content

Abstract

Study objective: To determine whether use of the T-System (Emergency Services Consultants, Irving, TX) template-generated medical documentation system (1) decreases physician evaluation time in the emergency department, (2) increases gross billing under the 1997 Health Care Financing Administration guidelines by minimizing downcoding caused by inadequate documentation, and (3) increases physician satisfaction with the documentation process, compared with the undirected written narrative format. Methods: A prospective, randomized, unblinded, controlled, convenience trial of documentation with the T-System of ED templates versus undirected written documentation was conducted in the ED of a county-owned, university-affiliated hospital. All patients seen between the hours of 7 AM and 10 PM during a 16-day period were included. The intervention was varying the method of documentation of the emergency physician. Adequacy of randomization to the 2 documentation groups was assessed by comparing ED triage classification, patient disposition, level of training of the evaluating physician, and whether ED consultation with other services occurred. Outcome measurements included emergency physician total evaluation and treatment time, professional bill, and satisfaction, as evaluated by a questionnaire completed after the study period. The 2 documentation groups were compared by an intention-to-treat analysis and by Student’s t test and the median test as appropriate. Results: A total of 1,228 patient encounters were included. Emergency physician total evaluation and treatment time with template-directed documentation was 4.6 minutes less than with undirected recording, a difference that was not significant (95% confidence interval [CI], –9.2 to 18.3). Gross billing was $29.60 more per patient (95% CI, $22.20 to $37.00) with the T-System, as assessed by our hospital coders. This difference was caused by a mean .50 (95% CI, .39 to .60) higher level of evaluation and management coding. Physicians preferred the T-System (P <.0005). Conclusion: Use of template-assisted documentation in the ED was associated with higher gross billing and physician satisfaction but no significant decrease in emergency physician total evaluation time. [Marill KA, Gauharou ES, Nelson BK, Peterson MA, Curtis RL, Gonzalez MR: Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med May 1999;33:500-509.]

Section snippets

INTRODUCTION

Emergency physicians currently use a variety of methods for medical documentation. These include unformatted and formatted written charts,1, 2, 3, 4, 5 dictated charts,6, 7, 8 and keystroke-driven and voice-activated computerized systems.9, 10, 11, 12, 13, 14

There are many motivations for improvement of the medical record in the emergency department. Improvement in medical care may be foremost. There is evidence that the quality and type of medical documentation is associated with the quality

MATERIALS AND METHODS

We performed a prospective, randomized, unblinded, controlled trial to compare use of the T-System ED template documentation method with undirected written documentation by emergency physicians in our ED over a 16-day period. We measured and compared the duration of physician evaluation and treatment, total physician billing, and physician satisfaction for the 2 methods. Assuming a standard deviation of 50 minutes in physician time or $50.00 in total bill, we chose the study duration to ensure

RESULTS

There were 1,228 patient encounters in the study. There was no emergency physician documentation on 1 trauma patient who was seen jointly with the surgical service, and this chart was excluded from further analysis. Physician noncompliance with randomization was noted with 48 patients (3.9%). In these cases the emergency physician did not follow the randomization rules and used a T-System chart in lieu of an unformatted chart, or vice versa (Table 1).

. Compliance with randomization: medical

DISCUSSION

We made no objective assessment of the fact-gathering capabilities of either documentation method in this study. It has previously been shown in multiple settings that preprinted assessment records garner more relevant information.1, 2, 3, 4, 5, 22 This is not surprising. Templates can be written and modified to specifically address those issues that are thought to be most relevant given a particular chief complaint. A disadvantage of templates is that they can never include all of the infinite

Acknowledgements

The authors thank Mrs Jackie Davis of TERM Billing Inc for generously donating her time and expertise. We also acknowledge the assistance with data collection, critical review, and general support provided by Matthew J Walsh, MD.

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^☆: Neither the authors nor the independent agency used to audit the charts had any financial interest or arrangement with the producers of the T-System.

^☆☆: Reprints not available from the authors.

^★: 0196-0644/99/$8.00 +0

^★★: 47/1/97456

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Prospective, Randomized Trial of Template-assisted Versus Undirected Written Recording of Physician Records in the Emergency Department☆,☆☆,★,★★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Am J Emerg Med

Int J Radiat Oncol Biol Phys

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

Improving the record of patient assessment in the trauma room

J Trauma

A new chart to assist with advanced trauma life support

J R Army Med Corps