Documentation of Health Risks and Health Promotion Counseling by Emergency Department Nurse Practitioners and Physicians

Purpose: The purpose of this study was to examine medical record documentation of health risk factors and health promotion discharge counseling by nurse practitioners and physicians practicing in an emergency department in the U.S. midwest. Methods: In this two‐group comparative study researchers examined random‐stratified medical records 305 nonacute ambulatory patients for selected health risk factors, including smoking, alcohol use, elevated blood pressure, obesity, and dental caries. Results: Fifty‐nine percent of this sample of relatively young adults (mean age = 33) had one or more health‐risk factors. According to medical record documentation, only 22% of these adults, with nonacute problems, received health promotion counseling. Multivariate analyses indicated that nurse practitioners were slightly more likely to provide smoking cessation counseling than were physicians. Conclusions: Many opportunities for identification of health risks and follow‐up counseling, as recommended in Healthy People 2000 and by the U.S. Preventive Services Task Force, were not documented. To meet the new goals of Healthy People 2010, health care providers in all settings should identify health risk factors and document health promotion counseling during every patient encounter.