ED History Taking

[chasingdaylight]

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Just wondering how the seasoned vets do it.

I find my self writing in short hand on a little note pad the history for each pt I see.

ie: cc: vomiting, x3d, nb,nb, saw PMD 3 days ago, no f, no d, no ha, no dysuria, no vag d/c. PMh..... Surg... social.... blah

I've tried doing things just by memory, and it works ok if I see 1 pt at a time and am not interrupted too often by some other ED calamity, but if I see 2 or 3 pt's at a time, too often I tend to forget which febrile pt had the vomiting, which only had nausea, and so on.

I'm thinking all this writing, then coming back to my desk and computer charting it all down is slowing me down.

What method do you guys/gals use?
Do you find you are more efficient if you take histories just by memory?

 

[EM2BE]

Have you tried writing just positives? If it's not written, then it's negative, esp if you tend to ask the same questions to everyone. I found if I see 5 abd pains on the board to be seen, I'll chart at least HPI, ROS and PE after each so I don't get them mixed up. Not that I'm seasoned, I just found that's what has been working for me.

 

[The White Coat Investor]

If you can't remember the entire history and physical, you're either asking too many questions or seeing too many patients between visits to the computer. I find the only thing I write down is the PCP and any specialists they see because for some reason I tend to forget this. I recently discovered my scribbles were getting scanned in and made part of the chart, so be a little careful what you write.

I find the most efficient system for me is to see 1 patient, then chart, then see 1 more, then chart. I do that 90% of the time. Almost every patient can wait another 1-2 minutes while I document the history, physical, diff dx, and a quick note about what I treated them with in the ED. I do the rest of the chart just before discharge and voila, no charting to do at the end of the shift and no forgetting who had what. But keep in mind I don't work in the busiest ED. I rarely average more than 2 patients an hour.

 

[pinipig523]

I print a list of the track board. See about 3 at a time.

I write complaint, duration, any other important associations. Then a few pertinent ROS/exam. Then maybe a T/E/D (for tob/etoh/drugs to cover social).

Then done. Onto the next one.

When I chart, I start with HPI then move on. The PE and other stuff can wait. I move through patients like this.

If it's slower, then I complete 3 notes at a time. If not, I just do 3 HPI at a time. Then onto the next ones.

 

[Mastodynia]

We have an EMR with computers in every room. I sometimes will chart in the room but there's usually awkward silence while I'm doing that. I'll do ordering in the room and then move on.

I have given up on the ROS and detailed HPIs. If patients go home, I only care to document enough for level 5 billing and medico-legal issues. If they are admitted, the hospitalist will do their massive HPI. Caveat the ROS except for what's documented in HPI. Physical exam you should remember the pertinent positives, have enough negs you';re used to documenting to get to level 5. PMH/PSH at our facility is entered by nursing so that's a breeze.

The rest is MDM and cake. If you are having trouble remembering things, write it down immediately in the chart before the bazillion interruptions hit you. Also don't be afraid to re-ask the patient.

In the end, if you don't document the patient had an appendectomy on an ankle sprain, who cares. If you didn't document they are diabetic on a STEMI, who cares. Document what you can, realize we have limited interaction with the patient, take a good history, provide good medical care, and document your thinking and MDM more than the nuts/bolts of the patient history.

 

[Groove]

Hmm. I grab a sticker, jot down VS, CC as I talk, quick and dirty abbreviations for PMHx, PCP and last seen by them. That's it. I do about 3-4 pt's and then chart HPI and PE and what orders I wrote. Sometimes when it's slammed, I might get as many as 6-7 behind but I don't seem to have a prob remembering. If you ask too many insignificant details, those you'll forget. Just ask the significant ones and you'll remember what they answer was because that's what's guiding your management.

There are some exceptions... Like cardiac pt's obviously I might write down a little more. If I saw one pt at a time and then charted, it would be easier and I prob wouldn't write anything but our ED is busy and I never know when I might get to sit down at the computer.

 

[chasingdaylight]

Good advice,

Thanks for all the input!