Chief Complaints, Emergency Department Clinical Documentation Systems, and the Challenge of Dealing with the Patient's Own Words

Application of information technology in medical sector is changing the practice in emergency medicine (EM). Clinical data would become widely available as emergency department and out-of-hospital clinical documentation systems mature and are adopted broadly, and may be used to support syndromic surveillance, ED operations, communication between providers, and research. The National Hospital Ambulatory Medical Care Survey (NHAMCS) performs an annual survey in general short-stay hospitals and uses a staged sampling strategy to portray ED care in the US. An ideal automated complaint-categorization system would advance health services research, syndromic surveillance, departmental quality improvement and the transition to electronic documentation. A documentation instrument that is customized for a particular complaint category may help technicians acquire and document important clinical information.