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Emergency medicine resident patient care documentation using a hand-held computerized device.
Summary
Emergency medicine residents using personal digital assistants (PDAs) showed increased documentation for some procedures but decreased for others, with no change in patient follow-ups. PDAs may offer time savings for residency programs.
Area of Science:
- Medical Education
- Emergency Medicine
- Health Informatics
Background:
- Accurate documentation of procedures and patient encounters is crucial for emergency medicine (EM) resident training and evaluation.
- Traditional paper-based or handwritten systems can be cumbersome and prone to errors.
- The integration of technology, such as personal digital assistants (PDAs), offers potential improvements in data collection and management.
Purpose of the Study:
- To evaluate the impact of implementing a PDA-based system on the documentation of procedures, patient encounters, and follow-ups by first-year EM residents.
- To compare the documentation rates between residents using PDAs and historical controls using a handwritten card system.
Main Methods:
- First-year EM residents were equipped with PDAs loaded with a customized program for recording procedures and patient encounters.
- Residents were instructed to log specific procedures and unstable patient cases.
- Data collected via PDAs were compared to data from a historical control group using handwritten cards.
- Statistical analysis, including Student's t-test, was used to compare documentation means between the groups.
Main Results:
- PDA use significantly increased documentation for conscious sedation, thoracentesis, and ultrasound procedures compared to the card system.
- Documentation of pericardiocentesis and evaluations of unstable pediatric surgical patients significantly decreased with PDA use.
- No statistically significant difference was observed in patient follow-up documentation between the PDA and card system groups.
Conclusions:
- Hand-held PDAs led to increased documentation for certain procedures and decreased for others among EM residents.
- While not all documentation metrics improved, PDAs offer potential time savings for creating resident procedure databases.
- Transitioning to PDA-based procedure logs could be an attractive option for EM residency programs.