Study objective: To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping.
Design: Nonrandomized case-control trial.
Setting: University-affiliated, tertiary referral hospital emergency department.
Methods: The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed.
Intervention: Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping.
Main outcome measure: The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping.
Results: Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed.
Conclusion: Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.