THE USE OF STRUCTURED, COMPLAINT-SPECIFIC PATIENT ENCOUNTER FORMS IN THE EMERGENCY DEPARTMENT

Study objective: To assess the effect of preprinted, structured, compl aint-specific patient encounter forms on documentation, use of testing , and treatment compared with free-text record keeping. Design: Nonran domized case-control trial. Setting: University-affiliated, tertiary r eferral hospital emergency department. Methods: The records of all pat ients with lacerations, pharyngitis, asthma, or isolated closed-head i njury during an eight-month period were reviewed. Intervention: Use of structured complaint-specific patient encounter forms versus traditio nal free-text record keeping. Main outcome measure: The null hypothesi s was that there would be no differences in documentation, test use, o r practice when the structured forms were used compared with free-text record keeping. Results: Differences in documentation that favored th e use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also w as affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed. C onclusion: Structured, problem-specific ED records improve documentati on and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as fo r medicolegal documentation. They provide a method for standardized qu ality assurance review and clinical data abstraction. Finally, they pr ovide a method for active dissemination of clinical standards.