Medicolegal woes often can be tracked back to poor documentation by the physician.
This article is a retrospective chart review of 384 EM resident charts, focusing on the documentation of the neurologic exam. Charts were selected if their chief complaints were neurologic or psychiatric in nature. A non-validated measurement tool for evaluating a neurologic exam was created based on discussions with attending emergency physicians. I have to agree with the chosen criteria. Documentation in each of the following criterion receives 1 point for a maximum score of 8.
- Level of consciousness
- Mental status
- Cranial nerves
- Motor function
- Sensory function
- Coordination
- Reflexes
- Gait
The primary outcome was the average documentation score. The secondary outcome was a change in documentation score as a function of resident training level (PGY 1, 2, or 3).
A linear mixed model analysis was used because of clustering of patients, based on residents. This methodology factored in the fact that individual residents examined more than one patient.
Results
The average documentation score = 4.26 (95% CI = 3.91-4.62), and interestingly the average scores did not change by resident training. There was a statistically significant difference between the neurological documentation score based on the type of chief complaint:
- Psychiatric complaint: Score = 3.97
- Neurologic complaint: Score = 4.55
As expected, some residents were inherently better documenters than others. The individual resident’s average scores ranged from 3.1 to 6.4.
Bottom line
For those giving feedback to residents (and medical students), pay special attention to their neurologic exam documentation. Documentation, while not an exciting part of patient care, is a crucial skill for residents in the ED.
Reference
Sarko J. Emergency medicine residents do not document detailed neurologic examinations. Academic Emerg Med 2009; 1371–3.
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