Background: Appropriate and timely documentation of rapid response events has been shown to have a significant impact on patient care and outcomes. Prior to January 2021, our institution did not have a standardized rapid response note template to facilitate best clinical documentation practices. A review of rapid response events at our institution that occurred during September 2020 found only 18% had a dedicated provider note, while only 4% included critical care billing. Additionally, many rapid responses at our institution and other academic centers are led by resident physicians who are still gaining experience and knowledge. A survey of 39 of the 65 first-year internal medicine residents at our institution revealed 100% did not feel confident in leading a rapid response, citing medical knowledge as their primary concern. A rapid response template with an augmented, emergency-specific assessment and plan has the potential to improve both documentation and clinical management.
Purpose: We created a streamlined rapid response note template with augmented, emergency-specific assessment and plan options to encourage quality documentation and supply key management cues to improve communication and patient outcomes. Additionally, we integrated an optional critical care time attestation for billable providers to increase the capture of billable time when appropriate.
Description: We created a rapid response template available at all four hospitals across our hospital system based on best practices defined in the literature and local expert opinion. To create the augmented assessment and plan, we first reviewed previous rapid responses at two academic hospitals within our institution and identified the most common emergencies encountered. We then created a selectable list in Epic containing high-frequency diagnoses. Once selected, a preformatted plan is pulled into the note (including suggested labs, imaging, procedures, medications, and management steps). This offers a structured approach to each scenario to ensure key actions are not overlooked and documentation is efficient and complete. Plan content was selected based on society guidelines and local expert consensus. Since note authors have varying levels of clinical experience, they have the option to use or forgo this augmented plan and can edit, delete, or add to any given event-specific plan. Additionally, for billable providers, an optional critical care billing statement appears automatically within the note to streamline this documentation process.
Conclusions: Our rapid response note template provides a structure to encourage quality documentation of rapid response events and provides management cues to improve care by novice providers, such as resident physicians. Future work is needed to compare note usage and quality following template implementation, as well as rapid response management and patient outcomes using the augmented assessment and plan.
