Emergency Department Encounter Record

Introduction

This is a draft of the Emergency Department Encounter Record supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Emergency Department Encounter Record is a summary of the patient’s health status, and a record of care rendered between ED arrival and ED discharge. The ED encounter is an episodic medical summary with a focused scope that fulfills a number of collaborative transfers of care.

Glossary

EDIS

An Emergency Department Information System (EDIS) is an extended EHR system used to manage data in support of Emergency Department patient care and operations. The functions of an EDIS may be provided by a single application or multiple applications.

Issue Log

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References

1. Emergency Care Special Interest Group, Health Level 7:Emergency Department Information Systems (EDIS) Functional Profile. Draft Version 1.04 (3/2/2007)

Volume 1

Add the following bullet to the list of profiles

• Emergency Department Encounter Record (EDER) is a summary of the patient’s health status as well as a record of care rendered in the ED between arrival and ED discharge. The ED encounter is an episodic medical summary with a focused scope that fulfills a number of collaborative transfers of care. The ED encounter record is a multi-authored document, recording the the patient's health status on ED arrival, as well as the assessments and care delivered by the entire ED team, including physicians, nurses, technologists and other providers. The ED encounter record may include links to diagnostic tests performed during the ED encounter, as well as links to an initial ED referral (a 2006 IHE work product), prehospital (EMS) records (IHE roadmap 2008), and the consultations of other providers for patients seen in the ED.

Profile Name

Use Case

Emergency Department Visit

This use case presumes the patient is cared for at a hospital facility with an EDIS as well as a hospital information system. Additionally, the patient’s primary care provider is also assumed to posses an interoperable EHR system. This use case begins upon the arrival of the patient to the emergency department. Data including mode of arrival, chief complaint, and other arrival data are manually entered into the EDIS. additional data including past medical problems, medications and allergies, are obtained in one of the following ways:

1. Entered manually into the EDIS by the triage nurse
   
2. Imported from a legacy ED encounter within the EDIS
   
3. Imported from an Emergency Department Referral (Emergency_Department_Referral, IHE 2006-2007)
   
4. imported from a prehospital EMS report (Emergency Medical Services (EMS) to Emergency Dept Data Transfer, PCC_Roadmap)
   

The patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, non-urgent). The patient is then registered and demographic data is obtained. One taken to the treatment area, the patient undergoes additional assessments by a primary RN, and seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient. Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility. Hence, the use case can take one of three branches:

1. If admitted, the EDER is sent to the hospital information system where it can be viewed by providers, or read by the EHR system so that medical summary data and details of care rendered in the ED available to inpatient providers.
   
2. If the patient is discharged the EDER is sent to the patients primary care physician as a summary of care rendered during the ED encounter.
   
3. If the patient is transferred to another facility, the EDER is posted to the RHIO and made available for providers at the receiving facility.