An Evaluation of Controlled Terminologies for ED Chief Complaint Documentation in the Department

Article Outline

• Purpose
• Design/Setting
• Sample
• Methodology
• Results
• Conclusions
• Copyright

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Purpose 

Chief complaint data from patients' visits to the emergency department (ED) are used to support clinical care, surveillance, and research efforts. Current chief complaint data have limitations due to poor quality and lack of standardization. To document chief complaints, many emergency departments use electronic systems that include a controlled list of predefined terms to choose from, as well as an option to enter free text. However, preliminary evidence suggests that nurses who prefer to document the chief complaint in free-text form bypass the controlled lists often. This study evaluated the content and use of chief complaint (CC) lists in two emergency departments.

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Design/Setting 

This retrospective, descriptive study was conducted at the emergency departments of one teaching and one community hospital in the Southeastern United States. Nurses from both departments documented CCs by choosing terms from an electronic drop-down pick list and/or by entering free text. The teaching hospital list included 1,680 terms, and the community hospital list contained 68 terms.

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Sample 

Electronic chief complaint data were collected for all visits at both departments from July 1, 2003, to June 30, 2004. Data from all 48,652 visits at the teaching hospital and all 63,039 visits at the community hospital were included. No patient identifiers were collected.

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Methodology 

Researchers compared nurses' CC entries to their departments' CC list to identify patterns of use. Data from both hospitals were analyzed to determine whether the chief complaints were: (1) Chosen directly from each site's controlled list; (2) Chosen from the controlled list along with additional information typed in free-text format; or (3) Entered as different CC terms in free-text format.

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Results 

Fifty-four percent (n = 26,434) of the CC entries at the teaching hospital matched terms from the controlled list, but only 36% (n = 600) of the 1,680 terms were used. The most common free-text entries included synonyms for controlled terms, as well as concepts not on the list. For example, abd pain or stomach pain was sometimes used for the controlled term abdominal pain. All of the CC entries in the community hospital records matched controlled terms, and all 68 terms were used. The most common CCs documented were “GI complaint” (11%) and “pain” (10%). The option of “other” was used 4% of the time, and explanations were entered as free text. In addition, nurses entered information pertaining to general CC terms in free text to offer more detailed descriptions. For example, pain was described in free text using the words abdominal (27%), back (25%), and leg (11%).

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Conclusions 

Findings suggest that nurses encountered system constraints when documenting chief complaints in the emergency department. Nurses often bypassed the controlled list in favor of entering noncontrolled terms in free text. These results indicated a need for improvements in user interface design, standardized lists of CC terms, and staff training to improve CC documentation in the emergency department and enhance the usefulness of CC data.