Assignment task: The emergency department (ED) chair has asked for a documentation audit of ED records. Your staff conducted the audit, the results of which were very poor. There was no consistency in the ED record documentation. You check the medical staff by-laws and realize that there are no specific guidelines related to ED documentation.
a. Determine documentation requirements for ED reports. List them here.
b. Audit the five representative ED cases below to determine the major areas in need of documentation improvement. As HIM director, present your results in a short memo to the ED department chair, Dr. Wilkerson.
c. Create a new section for the medical staff by-laws that incorporates ED documentation requirements. Include this in the memo to the chief of the ED for his approval before it continues through the formal process for inclusion into the by-laws.
d. The timing for this coincides with the transition of ED documentation into an electronic format. You propose to utilize the electronic record to facilitate the appropriate data collection. Create a screen design that encompasses the required ED documentation data elements.