Charting in the ED- buzzwords?

[emtPA]

I am interested in what you find is necessary to chart when working in the ED. Ie- not worst headache of life relating to HA. For sore throat- no drooling, no tirismus, uvula midline, etc. What are key things you chart, be it in physical exam, medical decision making, or in their dispo? 

[EMEDPA]

"considered, but doubt xyz dx due to abc".  For example: PE unlikely with Geneva score of zero, no specific risk factors, and stable VS without hypoxia, tachycardia, or tachypnea.

I use a lot of rules directly in my note like pecarn, heart scores, Geneva, curb-65, etc

[emtPA]

3 hours ago, EMEDPA said:

"considered, but doubt xyz dx due to abc".  For example: PE unlikely with Geneva score of zero, no specific risk factors, and stable VS without hypoxia, tachycardia, or tachypnea.

I use a lot of rules directly in my note like pecarn, heart scores, Geneva, curb-65, etc

Awesome, thanks so much! Figuring out the best things and necessities to chart is definitely more difficult than I anticipated. 

[thinkertdm]

Put a good reason as to why you went with the diagnosis you did- and just leaving it off doesn't make it disappear.  Remember, you are documenting for three reasons: to keep track for yourself, for legal and billing, and to tell the next provider what you did and why you did it. "Low suspicion for xyz due to lack of fever, normal labs, etc".  This is true in any clinical scenario, not just the Ed. 

[sas5814]

Our ER generally lists "differential diagnosis includes" and lists 4 or 5 other things they considered and eliminated along with appropriate follow up instructions.

[EMEDPA]

I would warn against using a macro or scribe prepared list for your DDX, because if you don't actually rule out everything on the list and they end up having something listed, you are in for a challenge if legal action is taken. the ddx is different for every specific pt and presentation so don't use macro lists unless you edit them very carefully, removing everything you think they don't have. it is embarrassing to say they might have endometriosis if they are male or might have an appy if it was already removed.

if you  list AAA on your ddx you better have a negative cta of the chest/abd/pelvis before you say you have excluded it. remember a DDX is a list of things you think the pt might realistically have. if they have 2/10 epigastric pain worse after eating a spicy taco and better with tums and they are 22 years old and have no hx of htn you probably should not list AAA on your ddx. You can say something like " I do not suspect any significant surgical pathology such as appy, diverticulitis, AAA, etc due to pts H+P and reassuring labs and diagnostic studies."

[medic25]

Agree with E about citing decision rules.  I'll always try and document the patients ability to ambulate for things like back pain, hip pain, etc.

e.g.  "patient able to ambulate without assistance and no visible limp, doubt occult hip fracture..."