title: Emergency department documentation templates: variability in template selection and association with physical examination and test ordering in dizziness presentations.
abstract: BACKGROUND
  Clinical documentation systems, such as templates, have been associated with process utilization. The T-System emergency department (ED) templates are widely used but lacking are analyses of the templates association with processes. This system is also unique because of the many different template options available, and thus the selection of the template may also be important. We aimed to describe the selection of templates in ED dizziness presentations and to investigate the association between items on templates and process utilization.
  
  
  METHODS
  Dizziness visits were captured from a population-based study of EDs that use documentation templates. Two relevant process outcomes were assessed: head computerized tomography (CT) scan and nystagmus examination. Multivariable logistic regression was used to estimate the probability of each outcome for patients who did or did not receive a relevant-item template. Propensity scores were also used to adjust for selection effects.
  
  
  RESULTS
  The final cohort was 1,485 visits. Thirty-one different templates were used. Use of a template with a head CT item was associated with an increase in the adjusted probability of head CT utilization from 12.2% (95% CI, 8.9%-16.6%) to 29.3% (95% CI, 26.0%-32.9%). The adjusted probability of documentation of a nystagmus assessment increased from 12.0% (95%CI, 8.8%-16.2%) when a nystagmus-item template was not used to 95.0% (95% CI, 92.8%-96.6%) when a nystagmus-item template was used. The associations remained significant after propensity score adjustments.
  
  
  CONCLUSIONS
  Providers use many different templates in dizziness presentations. Important differences exist in the various templates and the template that is used likely impacts process utilization, even though selection may be arbitrary. The optimal design and selection of templates may offer a feasible and effective opportunity to improve care delivery.
authors: Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA. kakerber@umich.edu
authors: Kevin A
authors: KA
authors: Kerber
authors: Timothy P
authors: TP
authors: Hofer
authors: William J
authors: WJ
authors: Meurer
authors: A Mark
authors: AM
authors: Fendrick
authors: Lewis B
authors: LB
authors: Morgenstern
mesh_terms: D000328:Adult; D000368:Aged; D059019:Clinical Coding; D004244:Dizziness / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D004636:Emergency Service, Hospital; D005260:Female; D006257:Head / Q000000981:diagnostic imaging; D006801:Humans; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D009760:Nystagmus, Physiologic; D017063:Outcome Assessment, Health Care; D010808:Physical Examination / Q000379:methods*; D011446:Prospective Studies; D013781:Texas; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*