Patient Medical Records in the Emergency Department

Revised and approved by the ACEP Board of Directors April 2009 and February 2002 titled, "Patient Medical Records in the Emergency Department"  

Originally approved by the ACEP Board of Directors January 1997 titled, "Patient Records in the Emergency Department" 

The American College of Emergency Physicians (ACEP) believes that high-quality emergency department (ED) medical records promote improved patient care. Many types of medical records are currently used including handwritten, transcribed, templated, and electronic medical records. Emergency physicians should play a lead role in the selection of medical record documentation systems for the ED.  

An effective ED medical record assists with: 

• documentation of clinically relevant aspects of the patient encounter 
• incorporation of laboratory, radiologic, and allied health testing results 
• legibility (avoiding "do not use" abbreviation use) 
• clear communication with other providers 
• coordination of follow-up care 
• discharge instruction communication 

When implemented successfully, a high-quality ED medical record should accurately capture the process of evaluation, management, medical decision making and disposition of a patient. It should facilitate quality assessment, quality improvement, and risk management activities and not interfere with physician productivity. The ED medical record should be promptly available after the patient encounter. 

Hospitals should provide emergency physicians the same access to dictation and transcription services as is provided to other hospital medical staff. 

ED medical records should be managed in compliance with applicable state and federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996.