Emergency medicine residents do not document detailed neurologic examinations.
OBJECTIVE
Physical examinations performed by residents in many specialties are often incomplete and inaccurate. This report assessed the documentation of the neurologic examination performed by emergency medicine (EM) residents when examining patients with potential psychiatric or neurologic chief complaints.


METHODS
A retrospective chart review of neurologic examinations documented by EM residents was performed. An eight-item neurologic examination score was created and analyzed by resident postgraduate year. A linear mixed model was used to determine if differences in neurologic examination scores existed between resident year, type of complaint, and resident year and type of complaint. A one-point difference in scores was considered clinically important.


RESULTS
A total of 384 charts were reviewed. An average of 4.26 items (95% confidence interval [CI] = 3.91 to 4.62) out of a possible eight were documented that did not vary by resident year of training (p = 0.08). An effect was found for type of complaint. Documentation was lower for psychiatric than for neurologic complaints: mean score for psychiatric complaints 3.97 vs. mean score for neurologic complaints 4.55 (difference -0.58, 95% CI = -1.02 to -0.14). No interaction was found for type of complaint and resident year. A clustering effect was identified for individual residents.


CONCLUSIONS
Emergency medicine residents do not document detailed neurologic examinations on patients with neurologic or psychiatric complaints. Individual resident variation contributes to this documentation.
Sarko
John
J
D000328:Adult; D004282:Documentation / Q000706:statistics & numerical data*; D004522:Educational Status; D004635:Emergency Medicine / Q000193:education* / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data*; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis; D009422:Nervous System Diseases / Q000175:diagnosis; D009460:Neurologic Examination / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States