Clinical procedures performed by emergency medicine resident physicians: A computer-based model for documentation

• Published in: The Journal of emergency medicine Vol. 9; no. 3; pp. 157 - 159
• Main Authors: Gail Ray, V., Garrison, Herbert G.
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.05.1991; Elsevier
• Subjects: Biological and medical sciences; clinical procedures; computer; Documentation; emergency medicine; Emergency Medicine - education; Emergency Service, Hospital; Hospital Information Systems; Internship and Residency; Medical sciences; Public health. Hygiene-occupational medicine; residency; residency; computer; clinical procedures; emergency medicine; Biomedical data processing; Professional practice; Internal; Physician; Emergency; Professional activity; Public health; Computer aided analysis
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/0736-4679(91)90329-E

To facilitate documentation and assess the number and types of clinical procedures actually performed by resident physicians, we developed a microcomputer-based recording process. After completing a procedure, including resuscitations, residents recorded in a precoded book issued for each monthly rotation. At the end of each rotation, the books were collected and the information was transferred to a database program by the clerical staff. During 1989, 17 emergency medicine resident physicians at PGY levels 1 through 3 utilized this system. Completed procedure record books were submitted for 124 of 148 clinically active months for a compliance rate of 84%. Of 1,857 procedures recorded, the most frequent were resuscitation (20%), orotrachael intubation (12%), and percutaneous central vein cannulation (12%). Commonly recorded were lumbar puncture (7%), diagnostic peritoneal lavage (5%), nasotrachael intubation (4%), and newborn delivery (4%). The high compliance rate suggests resident physicians acceptance. This system enables residency directors to closely monitor individual and group procedure experiences and to make curriculum changes based on objective findings. It also provides a means of storing and retrieving data for review organizations and credentials committees.