In modern medicine, the need for efficient, timely, and accurate charting is a reality. And, as most residents know, it can be a major burden. For those of you who still live in the glorious world of the T sheet, just wait: the EHR is coming your way. At times, residents can feel incredibly bogged down by the system, as it can be quite complicated. If you use an EHR for charting, you know it is an entire knowledge/skill set on its own separate from the medical knowledge required to complete your residency. So what are you to do?
Enter Dr. Michael Bohrn. Dr. Bohrn is our EM Residency Program Director at Wellspan York Hospital (@WellSpanYHEMDoc). Besides being an EKG guru, program director, and all around darn fine American, Dr. Bohrn is also incredibly knowledgeable in the realm of charting and coding. I have asked him to help out with some charting pearls for residents (and attendings alike). We will be looking forward to more from Dr. Bohrn (and you can follow him on Twitter @bohrnma for EKG and charting pearls). For his first installment, let's talk about the diagnoses listing:
To quote the late David Eitel, M.D. (founding Program Director at @WellSpanYHEMDoc), the Diagnosis line should "tell the story of the ED visit".
What this means is that you should include the main/most serious reason for the patient's visit as the first diagnosis (usually a symptom/finding, NOT a mechanism), then include modifying/other diagnoses which help tell the tale of the visit. As an example, say you take care of a middle age/elderly patient with a history of chronic pain, on chronic pain meds. Now she presents to ED with a recent fall and chest pain from the fall, as well as some opioid withdrawal. Since xrays were obtained, it is important to include a diagnosis which explains the X-rays and other workup.
A good diagnosis line for this patient in the setting of a negative X Ray would read as follows: 1. Acute chest pain/chest wall contusion 2. s/p recent fall with chest injury 3. acute opioid withdrawal 4. h/o chronic pain
This one line explains most of why the patient was there, why some of the management was chosen and justifies the xrays as workup for chest wall injury.
Diagnosis #2 is called an "E-code". These refer to mechanisms of injury in most cases and should NEVER be your primary/first diagnosis, since they're really modifying factors, not the injury/illness with symptoms requiring treatment.
When in doubt, you can use the presenting symptom/symptoms as a diagnosis (i.e. acute nausea and vomiting), but always try to include more significant/serious diagnoses when possible. For example, take a patient who presents with a fall and chest injury. The CXR shows a moderate pneumothorax requiring treatment. For this one, the diagnosis would something like: 1. Acute traumatic left pneumothorax 2. Fall (note: fall is not your first diagnosis).
Remember, your diagnosis should tell the story of the visit. Put the most serious conditions first. Use signs and symptoms if needed but serious diagnoses always trump these. and feel free to use "E codes" (mechanisms of injury), but never as the first/primary diagnosis. Happy charting!