Study objectives: Documentation of medical encounters has received much attention in the medical literature. Emergency physicians place themselves at risk of litigation by not adequately documenting all aspects of the medical encounter. The reexamination remains one of the most important documentation actions for the emergency physician. This crucial part of the patient encounter has several medicolegal ramifications. We examine the change in documentation of the reexamination by emergency physicians before and after the institution of the T-System preformatted documentation templates.

Methods: A retrospective medical record review was completed in the emergency department (ED) on consecutive patients with a chief complaint of abdominal pain from the first 2 months in 2001 and 2003, covering before-and-after implementation of the T-System. Records were examined for documentation of a reexamination after evaluation of abdominal pain. Frequency analysis was completed on the 2 subsets of data.

Results: The documentation rate of reexamination was 51.2% (64/125) before T-System implementation, whereas post–T-System results indicated reexamination completion at a lower rate (43.8%, 99/226), which was an unexpected 7.4% worsening of documentation after T-System (95% confidence interval –3.5% to 18.3%, P=.183).

Conclusion: Institution of the T-System did not affect the frequency with which physicians document reexaminations in the ED. Although the T-System may be valuable for other reasons, there is no evidence that using preformatted templates such as the T-System will improve physician documentation of the reexamination.