Emergency medicine resident documentation

Results of the 1999 American Board of Emergency Medicine in-training examination survey

J. Howell, C. Chisholm, A. Clark, L. Spillane

Research output: Contribution to journalArticle

29 Citations (Scopus)

Abstract

Objectives: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum. Methods: A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors pre-validated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. Results: Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters are most frequently documented on free-form handwritten charts (38%), and a total of 76% of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent 'never' record their supervising faculty's involvement in patient care, and another 25% record that information '1-25%' of the time. Seventy-nine percent are 'never' or 'rarely' requested by their faculty to clarify or add to medical records for billing purposes. Only 4% of the EM residents were 'extremely confident' in their ability to perform billing and coding, and more than 80% reported not knowing the physician charges for services or procedures performed in the ED. Conclusions: The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to over-estimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED.

Original languageEnglish (US)
Pages (from-to)1135-1138
Number of pages4
JournalAcademic Emergency Medicine
Volume7
Issue number10
StatePublished - 2000

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Emergency Medicine
Documentation
Medical Records
Hospital Emergency Service
Patient Care
Centers for Medicare and Medicaid Services (U.S.)
Guidelines
Surveys and Questionnaires
Internal Medicine
Medicare
Clinical Coding
Curriculum
Physicians

Keywords

  • Administration
  • Billing
  • Documentation
  • Health care finance
  • Medicare
  • Survey

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Emergency medicine resident documentation : Results of the 1999 American Board of Emergency Medicine in-training examination survey. / Howell, J.; Chisholm, C.; Clark, A.; Spillane, L.

In: Academic Emergency Medicine, Vol. 7, No. 10, 2000, p. 1135-1138.

Research output: Contribution to journalArticle

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abstract = "Objectives: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum. Methods: A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors pre-validated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. Results: Completed surveys were returned from 88.5{\%} of the respondents. A small minority of the residents code their own charts (6{\%}). Patient encounters are most frequently documented on free-form handwritten charts (38{\%}), and a total of 76{\%} of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent 'never' record their supervising faculty's involvement in patient care, and another 25{\%} record that information '1-25{\%}' of the time. Seventy-nine percent are 'never' or 'rarely' requested by their faculty to clarify or add to medical records for billing purposes. Only 4{\%} of the EM residents were 'extremely confident' in their ability to perform billing and coding, and more than 80{\%} reported not knowing the physician charges for services or procedures performed in the ED. Conclusions: The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to over-estimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED.",
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