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Title: Variables associated with completeness of medical record documentation in the emergency department.
Austin Authors: Lai, Fiona Wy;Kant, Joyce A;Dombagolla, Mahesha Hk;Hendarto, Andreas;Ugoni, Antony;Taylor, David McD 
Affiliation: The Royal Melbourne Hospital, Melbourne, Victoria, Australia
Bairnsdale Regional Health Service, Bairnsdale, Victoria, Australia
Goulburn Valley Health, Shepparton, Victoria, Australia
Eastern Health, Melbourne, Victoria, Australia
Centre for Epidemiology and Biostatistics, The University of Melbourne, Melbourne, Victoria, Australia
Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia
Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
Issue Date: 28-Jan-2019 2019-01-28
Publication information: Emergency Medicine Australasia : EMA 2019; 31(4): 632-638
Abstract: The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED. We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression. The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge destination and doctor gender were not associated with documentation completeness (P > 0.05). Patients with triage category 3 or pain score of 6-7 had higher documentation scores (P < 0.05). Compared to interns, registrars (effect size -0.72, 95% CI -1.02 to -0.42, P < 0.01) and consultants (-1.62, 95% CI -1.95 to -1.29, P < 0.01) scored significantly less. The headache patient subgroup scored significantly less than the other patient subgroups (-0.35, 95% CI -0.63 to -0.08, P = 0.01). For all presenting complaint subgroups, examination findings were less well documented than history items (P < 0.001). Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.
DOI: 10.1111/1742-6723.13229
ORCID: 0000-0002-8986-9997
PubMed URL: 30690885
Type: Journal Article
Subjects: documentation
emergency department
medical record
Appears in Collections:Journal articles

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