Understanding Your Emergency Department Records

Many people receive care at nationwide hospital emergency departments (EDs) every day — some with acute emergencies, some with acute flare-ups of chronic conditions, and, for some, even for primary care. Regardless, each emergency room interaction is an opportunity for a fresh assessment of a patient in the context of a specific problem, with approximately 15 to 20% of patients being admitted to the hospital and others being routed to outpatient care pathways.

Common conditions for hospital admission include congestive heart failure, pneumonia, acute heart attack, and acute stroke. Considerable information is recorded in standard sections of a hospital ED chart and is useful for patients to understand.

Emergency Department Forms and Notes

The Admission Form. The admission form shows the date and time of entry to the ED, the patient’s name and address, guarantor of payment, emergency contact, insurance information, the patient’s primary care physician, and the hospital’s attending physician.

This form usually contains the reason for the visit or a list of diagnoses. Sometimes, discharge time and disposition information are also included, depending on the institution. A listing of events, medications, and providers can be part of this section, as well. If the patient arrived by ambulance, there will be another set of records available from the EMT transport service and any other advanced life support team involved in bringing the patient to the ED.

The Triage Note. This is the first clinical assessment of the patient in the emergency chart, typically done by a nurse, and directs patient care in busier hospital emergency rooms. The triage note includes the patient’s chief complaint as told to the triage nurse, vital signs, and pain scale rating. Proper triaging is important to determine the level of care the patient needs by a physician or nurse practitioner. It also determines the urgency and speed of the treatment. The note is date- and time-stamped and has the information allowing classification of the Emergency Severity Index from Levels 1 to 5. ESI 1 is for life-threatening conditions requiring immediate attention while ESI 5 conditions have no immediate need for medical care. (Some hospitals use a three-level system, emergent, urgent and non-urgent.) For example, correct triage for an ESI 1 patient, such as calling Code Grey for an acute stroke patient, catapults the patient into an immediate mode with all medical hands on deck where minutes matter. Failing to properly triage ESI 1 or 2 patients correctly can lead to diagnostic delays that cause injury.

The History & Physical examination (H&P) is the clinical note by the physician or nurse practitioner about the initial assessment and the plan for treatment. The History starts with the Chief Complaint which is the reason the patient came to the Emergency Department as told to and recorded by the doctor or medical provider. The History of Present Illness (HPI) documents the details about the condition or problem for which the patient presented and follows the Chief Complaint. It includes information about when the problem started, what kind of pain or discomfort it is, aggravating factors, mitigating factors and prior treatments. The HPI is followed by additional sections that include:

The Review of Symptoms (ROS) asks general questions about each organ system to identify additional problems that may or may not be related to the Chief Complaint.

A list of Medications that the patient is taking is recorded.

Allergies to medications and other allergens are listed.

The patient’s Past Medical History (PMH) and Past Surgical History (PSH) is obtained and documented in the record.

A Family History is taken detailing diseases and conditions that are present in other family members to help identify risk factors and areas for further inquiry.

A Social History documents the use of alcohol, drugs and sexual habits, which helps identify additional risk factors for disease.

History taking is followed by physical examination, available laboratory and imaging data, the
assessment and treatment plan.

The Physical Examination is a problem-focused evaluation, based on the chief complaint and HPI, looking for primary and secondary signs of possible causative conditions. Examinations of the head, neck, chest, lungs, heart, abdomen, pelvis, and/or extremities are performed as related to possible causes of the patient’s complaints. Laboratory data that may be included (if available) include complete blood counts, white blood cell counts, serum chemistries, and X-r ay results.

Consultation notes are part of the record if a request for a specialty consultation was made by the ED, such as by a cardiologist for suspected acute myocardial infarction or a neurologist for acute stroke. This note provides helpful information about the patient, looking specifically for problems in the specialty area that may be less apparent to ED providers who are more generalized. It allows more accurate admission or discharge decisions since the ED provider gets the benefit of a specialist’s expertise and sets the patient into an appropriate specialty care track.

Lab and Imaging Reports in the ED chart include blood work, electrocardiograms, X-ray, CT, MRI and ultrasound reports. This is vital information that supports the diagnosis and plan of treatment decided upon. It is also important as it provides a record of the patient’s blood values, electrocardiogram (ECG) tracings, and imaging findings over multiple visits over multiple years— snapshots over time that may show a trend or other developing condition. Abnormal findings in laboratory or imaging test results often require further work-up, even if incidental to the reason for the visit. If the laboratory or imaging information was unavailable at the time of the H&P, there will be a follow-up note or addendum that discusses the test findings. This will also be date- and time-stamped and is necessary prior to any discharge.

The Assessment & Plan are the culmination of the Emergency Department evaluation where the diagnosis and plan for further work up is documented. This determines the disposition of the patient whether for admission for treatment or remain in the ED for observation, or whether to discharge home.

The Discharge Orders are written for patients who are put into the outpatient care pathway. This will be date- and time-stamped, and the nurse who discharges the patient will be documented in the chart. In addition, patient education instructions are given about the conditions diagnosed, causes, home care instructions, and signs to watch out for.

Understanding the contents of the emergency department chart helps better understand the health care provider’s medical decision making, diagnosis and treatment plan. With more understanding, patients and their representatives can make better decisions and be more involved in their future care.