DOCUMENTATION RUBRIC

Make    sure    to    include:    
BRIEF OVERVIEW
- Age, sex, chief complaint
- Relevant symptoms and history
- Abnormal vitals
- Complete in 1-2 sentences
The first section is a simple introduction to the patient and their presentation to the ED. This is what you would say if you were asked to summarize the situation in 1-2 sentences. It should only include the presenting information, not what you did in the ED

The differential is the list of diseases or conditions your patient might have. It is probably the most important part of the note. This section demonstrates that you thought about all the really bad things that could be causing the patient’s symptoms. It is the logical foundation to justify your testing, treatment, and overall management of the patient. 

TESTING
- Rationale for ordering
- Address any abnormal results
- Why no further testing is needed
THERAPY
- Rationale for treatment
- Response to therapy
INITIAL DIFFERENTIAL
- Differential based on brief overview
- What can be ruled out based on H&P
- Minimum 3 diagnoses

explicitly discuss the differential because the plan follows directly from the differential

The judge and jury looking at this case multiple years from now cannot read your mind, you must explicitly describe what you are thinking if you want to have a defensible chart.

tips to help improve your differential:

What would any BC EM doctor think of given just the one liner
Include complications
Include other organ systems
Include other anatomical compartments
Include things that you can rule out with history/exam alone
Include things that are slightly related but that the patient obviously does not have
Include complications of the diagnosis to which you are anchored
This section is unfortunately not done once you reach this point. It will need to be revisited later. After you have the results of testing and response to therapy, you will be ready to narrow the differential.
Or admit that you cannot narrow the differential

INITIAL TESTING
- Rationale for tests ordered

- Rationale for treatment
reveal the thought process for the testing that you have ordered. Now that a differential has been constructed, you can use testing to help determine the likelihood of each of the items. Some of the testing you decide on is fairly obvious, especially to another physician or an expert witness reviewing your chart. The testing that is fairly obvious likely does not need much explanation. There may be other testing that is less obvious to someone else reading your chart, and the reason that you ordered these tests should be briefly described. A simple trick to make this section easier is to pair up every test that you have ordered with a disease process on the differential diagnosis. use this section to explain why you didn’t order testing that other  doctors may have ordered (even if you disagree with their rationale). Justifying why you DIDN’T do various tests can be just as important as justifying why you DID do certain tests. thorough history and exam are usually sufficient to rule out all but 2-3 items on the differential. A simple sentence can be used to describe these items: “Based on the history and examination, I feel that the likelihood of DIAGNOSIS is so low that no further testing in this regard is warranted”. For the remaining items on the differential not ruled out by history/exam, labs, imaging, EKG, etc… will be used to help further narrow the differential.
INITIAL THERAPY
Any treatment that deviates from the expected normal course should be documented and explained. Selection of treatment is often fairly self-evident, and the more relevant part to document is usually the response to the treatment.
UP    TO    DATE    DIFFERENTIAL
- Minimum 3 emergency diagnoses
- Diagnoses that are ruled in/out
- Conclusion based on results
- Common complications
DISCREPANCIES
- Nursing and EMS documentation
- Negative points only
Your documentation should address any discrepancies between your note and other people’s notes. The main sources of discrepancies are usually nursing notes or EMS notes. Any large discrepancies must be addressed, but it is also useful to make sure that any small discrepancies are avoided.  approach this issue in a way that will preserve a collegial working environment. If it is not possible, any large discrepancies should be explicitly noted and addressed.
AFTER CARE
- Treatment plan
- Follow-up
- Return Precautions
- Timeline
FINAL THERAPY
- Response to therapy
Documenting the response to the treatment you have given is important. The response you are monitoring for varies widely by treatment type. Some of these are highly subjective, such as pain level or intensity of anxiety. There are also some responses that are objective. Did the patient’s heart rate improve after being given IV fluids? It may be difficult to establish a cause/effect relationship between treatment and outcome, but it is important to at least record any correlation. If you are proposing a particular diagnosis, then the known treatments for this disease should provide some improvement. It is a red flag if you diagnose a patient with a condition but the treatment is not providing any improvement within a reasonable timeframe. The reasonable time frame varies widely by disease and treatment. hile documenting subjective improvement in a patient’s symptoms is useful, documenting objective vital sign changes is even more important.
FINAL TESTING
- Address any abnormal results
- Why no further testing is needed
Once we have all of the results of the tests we have ordered, we now must interpret the results. You should show how the results of these tests further rule out (or in) items on your differential. The best way to do this is to briefly comment on the results of the tests, using your own writing/interpretation. you should comment and interpret shows that you saw the results, understood its significance and reacted appropriately to address it.  

 “I have reviewed all lab and imaging results and noted all abnormalities”, which are similarly useless.  simply comment on the results that are relevant to you, and specifically show how you are synthesizing the results into a coherent clinical picture.

Finally, any significant abnormal findings should be commented on. Sometimes a result may actually add a disease to the differential or necessite further testing or treatment. Incidental findings that are non-emergent may not alter the differential during the current visit, but need to be communicated to the patient, and that communication needs to be documented.

FINAL DIFFERENTIAL
- Conclusion based on testing and why
- What the diagnosis is not, and why
- Common complications
There will be significant overlap here between the initial differential section, testing, and treatment. This is where the final synthesis of all of the information occurs. In this section you should make sure that all the emergencies considered in the initial differential have been shown to be so unlikely that no further testing is needed. Alternatively, you may have actually uncovered an emergency diagnosis, in which case this should be clearly stated. 



all charts should be written in a way that is legally defensible

Any expert witness reviewing the chart should be able to clearly follow your thought process

you do have to display clear and logical decision-making

documentation will include the basic elements to be reimbursed.



When being discharged, there are 3 important things that must be addressed to show that you safely discharged them.

Treatment Plan
Follow-up
Return Precautions
Each of these 3 areas should include specific timing instructions. The first is the treatment plan. What should the patient be doing at home to help manage their symptoms and treat their condition? A pain plan is often a part of this. Any medications you prescribe should be part of this. If you recommend using hot/cold packs, it should be included. They need to know what they should be doing at home and how often (timing of instructions are critical). The next part is the follow-up. Most patients will need to have a follow-up with their primary care doctor. They need to be told, specifically, how many days until they should follow-up. Ideally all patients could get follow-up the next day, but this is usually not possible, so make a reasonable guess. Usually 2-5 days is a reasonable approach. They need to be told specifically who to follow-up with. This is probably their primary care doctor, but if you can get subspecialty follow-up and it is appropriate, it should be mentioned. The patient should also know how this will be arranged. Should they call their primary doctor? Should they wait for a phone call from an orthopedic clinic? What should they do if they don’t get a phone call? Finally, the patient needs to be given return precautions. Return precautions are instructions for returning to the ED. They should usually be tailored to the patients symptoms or disease process. Sometimes we know specifically what to watch out for. Other times, its useful to include general precautions, including a vague statement about returning “if you develop any new or worrisome symptoms”. As with all aspects of aftercare, the patient needs to know, specifically, when to return to the ED. And the answer (at least, the defensible answer) is pretty much always to return immediately to the ED if your condition worsens. Many EDs use pre-written discharge instructions that are given to patients, which are generally helpful, but it is even more protective if you both give them and document the information described above.