Procedure documentation in emergency medicine residencies: a time of change

The purpose of this study was to identify the methods of procedure documentation (PD) used by emergency medicine residency programs and to ascertain the number of programs that are transitioning to a more advanced system.

All 122 ACGME-approved allopathic emergency medicine programs were contacted by telephone in December 2001. Survey information was obtained from the program director, an attending physician, a resident, or the residency coordinator.

The response rate was 92.6%. Seventeen programs (15%) reported using multiple methods of PD, with only 8% utilizing a formal database. Fifty-five percent reported that PD was manual. One third of all programs utilized a Web-based system for PD, while 13% required the use of personal digital assistants (PDAs). Nearly one fifth of programs stated they were changing to another form of PD, with the majority of those changing to a PDA format. Fifteen percent of programs purchased PDAs for their residents, and a similar proportion reported that the PDA was used by "most or all" of their residents to document procedures. Nearly four times as many programs (64%) reported that "most or all" of their residents utilized PDAs for clinical purposes.

PDAs are used by a majority of residents for clinical purposes, although fewer utilize this resource for PD. Although most emergency medicine residency programs still utilize a manual system for PD, many programs are in transition to a more technologically advanced method.