Emergency medicine resident patient care documentation using a hand-held computerized device

Objective: To determine whether emergency medicine (EM) resident documentat ion of procedures, patient encounters, and patient follow-ups improved afte r implementation of a personal digital assistant (PDA) hand-held recording system. Methods: All first-year EM residents were provided a PalmV (Palm, I nc., Santa Clara, CA) PDA. A customized patient procedure and encounter pro gram was constructed using Pendragon Forms (Pendragon Software Corporation, Libertyville, IL) and loaded into each PDA. Residents were instructed to e nter information on patients who had any of 21 procedures performed or were considered to be clinically unstable. These data were downloaded to the re sidency coordinator's desktop computer. The mean number of procedures, enco unters, and follow-ups performed per resident were then compared with those of a group of 36 historical controls from the three previous first-year re sident classes who recorded the same information using a handwritten card s ystem. Data from the historical controls were combined and the means of eac h group were compared by Student's t-test. Results: Mean documentation of t hree procedures was significantly increased in the PDA group versus the ind ex card system: conscious sedation 5.8 vs. 0.03 (p < 0.000005), thoracentes is 2.2 vs. 0.0 (p = 0.002), ultrasound 6.3 vs. 0.0 (p = 0.002). The mean nu mbers of pericardiocenteses and unstable pediatric surgical patient evaluat ions were significantly decreased in the hand-held group [from 1.2 to 0.4 ( p = 0.03) and from 9.1 to 2.2 (p = 0.02), respectively]. Patient follow-up documentations were not statistically different between the two groups. Con clusions: Use of a hand-held PDA was associated with an increase in first-y ear EM resident documentation in three of 20 procedures and a decrease in o ne procedure and the number of unstable surgical pediatric patient resuscit ations. The overall time savings in constructing a resident procedure datab ase, as well as the other uses of the PDAs, may make transition to a hand-h eld computer-based procedure log an attractive option for EM residencies.