Initial Clinical Impressions Are Absent in Around a Quarter of Adult Emergency Department Patient Consultations:...

Documentation of clinical impressions in ED electronic medical records is essential for diagnostic decision-making and effective patient management. We sought to evaluate the completeness of clinical impression documentation in initial ED medical assessments to identify gaps and inform future multimodal research interventions.

A structured retrospective medical record review of 500 randomly selected adult patients who presented to four Australian EDs between 1-31 August 2024 was conducted. The primary outcome was a documented clinical impression in the ED initial medical assessment. Secondary outcomes included analyses of relationships between predefined patient or clinical factors and the documentation of a clinical impression.

During the study period, 16 431 adults attended one of four Monash Health EDs. After exclusions were applied, 432 patient records were randomly selected for analysis. Clinical impressions were absent in 23.4% of cases (95% CI 20%-28%, margin of error 3.9%). This was consistent across levels of clinician experience and triage categories, except for category 5 with higher rates of absent clinical impressions (67%; 95% CI 31%-91%). Differential diagnoses were documented in 39% of cases. High urgency patients had more clinical decision rules documented (4%; 95% CI 2%-7% vs. 14%; 95% CI 8%-23%). Inter-rater reliability for the primary outcome demonstrated strong agreement (κ = 0.91).

Alarmingly, almost one-quarter of adult ED patients lacked a documented clinical impression in their initial medical assessment, irrespective of clinician experience and most triage categories. This gap should be addressed quickly to improve diagnostic decision making and protect patient safety.