Emergency medicine resident documentation: Results of the 1999 American Board of Emergency Medicine In-Training examination survey

Objectives: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of pati ent care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instructi on and formal didactic experience with this component of their curriculum. Methods: A survey was conducted consisting of closed-ended questions invest igating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taki ng the 1999 American Board of Emergency Medicine (ABEM) In-Training examina tion. Five EM residents and the Society for Academic Emergency Medicine (SA EM) board of directors pre-validated the survey. Summary statistics were ca lculated and resident levels were compared for each question using either c hi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. Resul ts: Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters ar e most frequently documented on free-form handwritten reported using handwr itten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record informatio n for a patient evaluated in their ED within the previous 72 hours. Twenty- five percent "never" record their supervising faculty's involvement in pati ent care, and another 25% record that information "1-25%" of the time. Seve nty-nine percent are "never" or "rarely" requested by their faculty to clar ify or add to medical records for billing purposes. Only 4% of the EM resid ents were "extremely confident" in their ability to perform billing and cod ing, and more than 80% reported not knowing the physician charges for servi ces or procedures performed in the ED. Conclusions: The handwritten chart i s the most widely used method of patient care documentation, either entirel y or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to overestimation of faculty noncompliance with HCFA billing guidelines. Emerg ency medicine residents are not confident in their knowledge of medical rec ord documentation and coding procedures.