New Page 1

Documentation

The HPI is a story that is condensed from the patient interview. It should be clear to someone who has never seen or examined the patient exactly what happened, and the exact progression of symptoms. It is not written for you or for me, but for the next physician who sees the patient, or for a payor or lawyer who has never seen the patient. It is not scut work— it is good medicine. The staff reads every chart. You will be evaluated primarily by your charting, as that is the record of your understanding of each case. It is also the record of your understanding of how to evaluate each patient's complaint or injury. Charting itself is as important as any part of the work.

The chart has a space for every portion of the history and physical exam. All must be done and documented. Discrepancies between your history and the nurse's note must be explained. Besides being complete, the physical exam must be directed towards the concern of the HPI.

There is a stereotype that emergency physicians are supposed to be less thorough than internists and others. Let us lay that to rest. We focus on stabilization first, but not at the expense of a thorough evaluation, which must be done, though perhaps after some procedures and tests are initiated.

Pain must be investigated in exquisite detail: When did it start? Was it sudden? Over 1 second, 1 minute, 10 minutes? Is it intermittent? If so, does it ever go away completely? Or is it constant? How long does the pain last? What were you doing when the pain started? What makes it worse

or better (e.g. eating, bending over, exertion, twisting, palpating, laughing, coughing, deep breathing)? Does it radiate? to where? how intensely? Is it sharp (like a knife) or sharp (severe), or pressure or burning or throbbing or stabbing or lancinating or indigestion or totally nondescript. Are there associated symptoms: nausea? vomiting? diarrhea (how many stools?

formed, unformed, or liquid?)? constipation ( when was the last stool?)? Dyspnea? diaphoresis? wheezing? hematemesis? hematochezia? vaginal symptoms (discharge, dyspareunia, dysmenorrhea, irregular periods, etc.) urinary symptoms (burning, urgency, frequency, hesitancy, dribbling)? and so on and on and on.

There is no clinical setting where accurate documentation is more important than in the ED. During a brief time period, working diagnoses must be reached and treatment frequently administered. Remember, the ED record is a vehicle for communication. Thorough, accurate documentation may ultimately prove life-saving. All charts will be reviewed with particular attention to the following standards of documentation.

Examples of a succinct pain history:

47 yo male states he was watching TV when had sudden onset over 3 sec severe squeezing SSCP w/o radiation (not back, arms, nor jaw) w/o SOB but w/diaph. No other assoc. Sx's. Pt. got up to walk around and pain completely resolved within 30 sec. States he could do nothing to bring on the Sx's again—not deep breath nor pushing on the spot. No Sx's since. Had once before. This episode not worse. Comes in this time because he told wife who is worried about heart. Non-smoker, no EtOH nor illicit drugs, no Fhx ofMI,

The following need to be documented within the HPI for any symptom based complaint:

•signs & symptoms     •Duration     •modifying factors

•location                     •Timing        •severity

•quality                       •context       •radiation