Documentation in the PECC
What is the purpose of the Physician Record?
The Physician Record is a legal record for the patient encounter in the PECC. It serves two
purposes:
 Demonstrates the information used in providing care for the patient
 Provides evidence for the amount of physician work
Basic documentation guidelines
Simply stated the Physician Record should reflect three things:
 What you heard (history)
 What you saw (exam)
 What you thought (assessment)
Keep in mind the ED record should be specific and direct as to why the patient is there and what
factors may be contributing to the visit. For example, you would not normally need to note that a
patient had a history of asthma if they were being seen for an ankle injury. However, if the patient
was being seen for a laceration, the fact that the patient’s asthma required daily steroids would be
important.
Your writing must be legible and readable to others. Be careful with the words and abbreviations
you use. If in doubt just write it out in plain English. Try to quote the historian as directly as
possible. Ask the historian to define ambiguous terms and enter that definition with the word in
the record. Avoid using imprecise words in your description of the patient.
For example, “lethargic” is a poorly defined medical term. If the historian was to say that there
child was “lethargic” ask them to define what they mean; “My child is lethargic = sitting around
watching TV all day.” Be precise in your patient description; “Sleeping but easily arousable to
voice.”
Identify who is providing the history e.g. mother, grandmother, teacher. Note if the patient arrived
by EMS and if any treatment was provided before arrival at the PECC. If the patient was
transferred from another facility indicate where and for what reason.
Never make any accusations in the Physician Record. Document facts and findings. What you
write may come back to trouble you later.
Specific charting guidelines
Always record the time and date of your examination. All times should be recorded in a 24 hour
format (8 am = 0800, 8 pm = 2000).
If the historian cannot communicate in English, mark who provided the translation (Box 1).
Mark the appropriate box if you are unable to obtain more then a partial history (Box 2).
Chief complaint: Just a few words as to the primary reason the patient came to the PECC.
HPI – History of the present illness: Clearly but briefly describe the issues related to why the
patient came to the PECC. The HPI is a chronological description of the development of the
patient’s present illness from the first sign and/or symptom to the present and includes some or
all of the following elements:
Documentation in the PECC
revised 7/15/05
Page 1 of 3








Duration
Severity
Quality
Timing
Location
Context
Modifying factors
Associated signs and symptoms
Review of systems: Indicate pertinent positives and negative related to the chief complaint.
Checking the box for “Other than already noted, all other systems reviewed and negative” means
that you have evaluated at least 10 of the 14 systems (including those already marked) (Box 3).
Past medical, family and social history: You must record pertinent information in at least the past
and social history.
Physical exam: Vital signs are transcribed from the nursing triage note or most recent set of vital
signs obtained when you see the patient. Do not circle or otherwise emphasize any abnormal
values. Any values that you find inconsistent with your exam should be documented in the
appropriate area of your exam.
For example if the respiratory rate documented by the nurse was 50 but the child is breathing at
20 during your exam then record “observed respiratory rate 20” in the respiratory exam section.
For all patients you must indicate if they are in pain and provide a general description. Pain
scales and scores are posted in some of the exam areas and on the back of the nursing triage
form. Avoid using terms like “WD WN NAD”. Use a few words to tell if the patient appears ill or
not: “Smiling, playful, active”, “Alert, well hydrated appearing”, “Marked increased work of
breathing”, “Sleeping, difficult to arouse to pain.”
Check “NL” (normal) if there are no abnormal findings in that organ system in your exam. Check
“Add” when recording pertinent normal or abnormal findings. Check “NoEx” if you do not exam
that particular area (Box 4).
Initial assessment, plan and differential diagnosis: Just jot down your initial thoughts.
X-ray results: You must indicate who performed the radiograph interpretation. Did you get a
written or verbal report from the Radiologist or did the PECC attending provide the primary
reading?
Reassessment
All patients who receive a treatment and/or who are under care for a prolonged period of time
must have a timed documented reevaluation. Use the reassessment area on the Respiratory
Care Record (asthma form) for respiratory patients (Box 5).
Shift change
You must record signouts if another physician takes over care of your patient in the PECC. The
physician who is taking over care must sign the chart here (Box 6).
Procedure note
All physician procedures must be documented in the medical record. You are required to discuss
the risk, benefits and alternatives with the patient or caregiver in order to have obtained an
informed consent. While the general ED consent signed by the caregiver will cover most
procedures performed in the PECC, you must document that the caregiver was informed. Check
Documentation in the PECC
revised 7/15/05
Page 2 of 3
the box for “Informed verbal consent” to indicate this has been done. Write in who gave the
consent.
Check off the procedure that you did. If no physician procedures were performed, be sure to
check the “No physician procedures” box (Box 7).
Complete the “conscious sedation” area if the patient required moderate or deep sedation for the
procedure (Box 8). Ask the attending physician to grade the patient’s ASA level.
Attending physician note
Do not write in this area (Box 9).
Consult
Be sure to note the time(s) you paged the consultant and the time they arrived in the PECC.
Discharge diagnosis
Discharge diagnosis is just that, the final determination for what was wrong with the patient.
There is no advantage to marking anything down when you first see the patient. Terminology and
order of what is listed here is very important.
The discharge diagnosis may be a disease entity or just the patient’s symptom or complaint. A
wheezing child could have a discharge diagnosis of asthma exacerbation or wheezing depending
on the circumstances. When in doubt ask the attending.
Condition on discharge
These terms are defined by the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), the organization that accredits hospitals. Here is what they officially mean and when
you would use them:




Good: Vital signs are stable and within normal limits, patient is conscious and
comfortable, prognosis is excellent. This patient would be discharged from the PECC.
Fair: Vital signs are stable and within normal limits, patient is conscious, but may be
uncomfortable, prognosis is favorable. This patient may be discharged or be admitted to
the hospital
Serious: Vital signs may be unstable and not within normal limits, patient is acutely ill,
prognosis is questionable. This patient would be admitted to the step down or critical care
unit.
Critical: Vital signs are unstable and not within normal limits, patient may be unconscious,
prognosis is unfavorable. This patient is admitted to the intensive care unit.
Disposition
Always record the time you and the attending have made the decision on patient disposition. This
may be the time you have completed your discharge paperwork and have placed the chart in the
discharge box or when the decision has been made to admit the patient. Check the “Admission”
box for all patients being admitted to the general wards (doesn’t matter if it observation or
inpatient status). Check the “Gen Peds” box regardless of whether it is the Emory or Morehouse
service.
Sign you chart.
Sign both pages and always print your ID (Grady) number.
Remember, good documentation is an important part of your patient care.
Documentation in the PECC
revised 7/15/05
Page 3 of 3