You should include the following items 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 suspected child, elder, or spousal 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 care- givers or providers regarding the patient;
- a patient’s leaving against medical advice;
- nurses’ signatures.
You should include the following items in your documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA.
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