Emergency medicine residents do not document detailed neurologic examinations.

Abstract

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. 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. 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. Emergency medicine residents do not document detailed neurologic examinations on patients with neurologic or psychiatric complaints. Individual resident variation contributes to this documentation.