Use this checklist when you document
You should include the following elements in your documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/ quality management at Lynx Medical Systems in Bellevue, WA:
- Timed and initialed entries
- Means of arrival
- A triage note or presenting problem and pertinent history of the illness or injury
- Allergies and current medications
- Important factors that put the patient at high risk per hospital policy (such as potential abuse)
- Weight, visual acuity, or other factors (if appropriate for age and presenting problem)
- Initial vital signs and a reassessment if abnormal or changed during the emergency department course of treatment
- All interventions and patient responses
- Some type of pain assessment scale
- Orders noted and initialed per hospital policy
- An assessment of the patient’s psychosocial needs and ability to understand teaching and instructions
- Discharge status
- Disposition and time
- Referrals and communications with other caregivers or providers regarding the patient
- A patient’s leaving against medical advice
- Nurses’ signatures
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