Standardized collection of presenting complaints in the emergency room : Integration of coded presenting complaints into the electronic medical record system of an emergency department and their value for health care research

Abstract

The point of entry of apatient in emergency care is asymptom or acomplaint. To evaluate subsequent processes in an emergency department until adiagnosis is made, this information has to be taken into account. We report the introduction of coded presenting complaints into the electronic medical record system of an emergency department and describe the patients based on these data. The CEDIS presenting complaint list was integrated into the emergency department information system of an emergency department (38,000 patients/year). After 8months, we performed an exploratory analysis of the most common presenting complaints. Furthermore, we identified the most frequent diagnoses for presenting complaint "shortness of breath" and the most frequent presenting complaints for the diagnosis of sepsis. After implementing the presenting complaint list, apresenting complaint code was assigned to each patient. In our sample (26,330 cases), "extremity pain and injury" comprised the largest group of patients (29.5%). "Chest pain-cardiac features" (3.7%) and "extremity weakness/symptoms of cerebrovascular accident" (2.4%) were the main cardiac and neurologic complaints, respectively. They were mostly triaged as urgent (>80%) and hospitalized in critical care units (>50%). The main diagnosis for presenting complaint "shortness of breath" was heart failure (25.1%), while the main presenting complaint for the diagnosis sepsis was "shortness of breath" (18.1%). Containing 171 presenting complaints, this classification was implemented successfully without providing extensive staff training. The documentation of coded presenting complaints enables symptom-based analysis of the health care provided in emergency departments.