Documentation in the pediatric emergency department: A review of resuscitation cases

Philip S. Schoenfeld, Mark Douglas Baker

Research output: Contribution to journalArticle

Abstract

Study objective: Documentation practices of staff physicians, residents, and nurses managing critically ill children were reviewed for completion of standard documentation requirements. Design: Retrospective chart review. Setting: Municipal children's hospital. Participants: 144 patients treated in the cardiopulmonary/trauma resuscitation room over a 17-month period. Intervention: Emergency department records of these patients were reviewed for medical information required by joint Commission on Accreditation of Healthcare Organizations guidelines: history of present illness, medical history, vital signs, physical examination, laboratory results, clinical observations, and diagnostic impression. In addition, the frequency of medical record review by legal representatives of the patient and by the state's social service agencies was evaluated. Results: Attending physicians demonstrated more complete documentation than residents in clinical observations of patients (36.4% vs 18.0%, P <.005) and diagnostic impression (97% vs 78.4%, P <.03). Nurses demonstrated more complete documentation than physicians, as a group, in laboratory results (83.9% vs 47.6%, P <.001) and clinical observations (80.6% vs 22.2%, P <.001). Sixty-six medical records (37.9%) were subjected to legal review: 37 (21.3%) by patients' legal representatives, and 29 (16.7%) by the state's social service agency. Conclusion: ED record documentation of pediatric patients treated in a cardiopulmonary/trauma resuscitation room often does not meet standard guidelines. Complete documentation is important due to the frequency of legal review of these records and the need to ensure post-ED continuity of care.

Original languageEnglish (US)
Pages (from-to)641-643
Number of pages3
JournalAnnals of Emergency Medicine
Volume20
Issue number6
DOIs
StatePublished - 1991
Externally publishedYes

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Resuscitation
Documentation
Hospital Emergency Service
Pediatrics
Patient Advocacy
Cardiopulmonary Resuscitation
Social Work
Physicians
Medical Records
Nurses
Guidelines
Joint Commission on Accreditation of Healthcare Organizations
Municipal Hospitals
Continuity of Patient Care
Vital Signs
Wounds and Injuries
Critical Illness
Physical Examination

Keywords

  • resuscitation, documentation, pediatric

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Documentation in the pediatric emergency department : A review of resuscitation cases. / Schoenfeld, Philip S.; Baker, Mark Douglas.

In: Annals of Emergency Medicine, Vol. 20, No. 6, 1991, p. 641-643.

Research output: Contribution to journalArticle

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abstract = "Study objective: Documentation practices of staff physicians, residents, and nurses managing critically ill children were reviewed for completion of standard documentation requirements. Design: Retrospective chart review. Setting: Municipal children's hospital. Participants: 144 patients treated in the cardiopulmonary/trauma resuscitation room over a 17-month period. Intervention: Emergency department records of these patients were reviewed for medical information required by joint Commission on Accreditation of Healthcare Organizations guidelines: history of present illness, medical history, vital signs, physical examination, laboratory results, clinical observations, and diagnostic impression. In addition, the frequency of medical record review by legal representatives of the patient and by the state's social service agencies was evaluated. Results: Attending physicians demonstrated more complete documentation than residents in clinical observations of patients (36.4{\%} vs 18.0{\%}, P <.005) and diagnostic impression (97{\%} vs 78.4{\%}, P <.03). Nurses demonstrated more complete documentation than physicians, as a group, in laboratory results (83.9{\%} vs 47.6{\%}, P <.001) and clinical observations (80.6{\%} vs 22.2{\%}, P <.001). Sixty-six medical records (37.9{\%}) were subjected to legal review: 37 (21.3{\%}) by patients' legal representatives, and 29 (16.7{\%}) by the state's social service agency. Conclusion: ED record documentation of pediatric patients treated in a cardiopulmonary/trauma resuscitation room often does not meet standard guidelines. Complete documentation is important due to the frequency of legal review of these records and the need to ensure post-ED continuity of care.",
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