Prospective, Randomized Trial of Template-assisted Versus Undirected Written Recording of Physician Records in the Emergency Department☆,☆☆,★,★★
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).
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.
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Reprints not available from the authors.
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0196-0644/99/$8.00 +0
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