Emergency Department Encounter Report (EDER)
The EDER is envisioned as a CDA implementation guide that encapsulates all of the documentation associated with an ED Encounter/Visit.
The EDER contains sections for the Triage Note, ED Nurse Assessments, ED Physician H&P,ED Critical Care, Resuscitation/CPR Note(s), Emergency Department Course, Diagnostic Studies, Procedures, Consultation, ED Plan of Care, ED Discharge Plan of Care, and Disposition.
EDER is designed to reflect practice more than convention
Emergency Departments function distinctly different from in-patient and out-patient settings. There is a distinctly different relationships between physicians, nurses, technicians and other members of the ED team, in part because everyone cares for patients in the same time/place together. Also, the ED is a high-tempo, high-data environment, where in a span of a few hours multiple different diagnostic considerations are addressed, critical care provided, and often multiple consultants involved.
The documentation should reflect this unique environs. The traditional H&P doesn't fit the process well, as often the whole ED process is reversed, where critical ill patients receive life-saving therapy first, then (often preliminary) diagnosis made, and eventually a full exam and history obtained (when possible). The H&P gathered at the start of an encounter, along with the initial evaluation and management may resolve a problem, with routine out patient followup, or it may unearth a series of issues which each results in a separate threat of investigation. Thus, the electronic representation can take advantage of those data structures which support each of these commonplace events, in a model which closely resembles reality better than the traditional (based on paper-bound processes, often with separate nursing and physician notes).
For example, a patient may present to the ED with several acute issues (e.g. respiratory distress, delirium, hypotension, etc.). Each of these is treated as a separate problem for the duration of the ED encounter. These may, or may not, be related to the patient's chronic medical problems (which may need attention during the course of the encounter as well, e.g. long-term steroid use with attendant adrenal insufficiency, congestive heart failure).
Initial diagnosis focus on the most lethal, not the most probable. Subsequent diagnostic considerations focus on establishing a correct diagnosis, rather than specifically addressing life-threats. This is not properly represented in most existing specifications. In the ED, the classic notion of a differential diagnosis focused on establishing the etiology is typically entertained after or concordant with initial efforts to focus on unlikely, but potentially dangerous conditions.