Documentation is a major element in the operation of the Emergency Center and in future patient care.
Please see the "Charting Technique Module" and "Guidelines for Documentation" located in the appendix.
Specific Charting Elements often Forgotten:
· Abdominal Pain: needs rectal/pelvic/urine pregnancy if women of childbearing age. ED recheck if unsure of diagnosis
· Chest Pain: cardiac risk factors if over 40
· Wound care: tetanus status, wound length, wound explored and irrigated
· Polydrug overdose: Tylenol and Aspirin levels
· Sore throat: uvula midline
· Extremity injury: distal neurovascular exam, and after splinting
· Low back pain: lower extremity DTR's
· Headache: fundi, neck stiffness, detailed neurologic exam (Don't write non-focal)
· Seizure: detailed neurologic exam
· Minor head injury: detailed neurologic exam
· Shortness of breath: pulse oximetry
· Eye complaints: visual acuity
Continuous Quality Improvement
A routine chart audit
is also done on all first-year residents by a third-year resident. These
audits are reviewed with the appropriate faculty preceptor and specific feedback
is provided on these cases to the first-year resident. Faculty review
these audits with the third-year resident before the final written feedback
is given to the first-year resident.
Dictations
Dictations may be done in lieu of typewritten notes
on ED patients but must be signed electronically. The dictation or typed note on the electronic medical record
(EMR) should occur at the time the patient is ready to leave the ED. The dictation
should include not just the initial evaluation, but any changes in the patient's
condition and subsequent intervention in the ED. A
note on the EMR will be completed by the ED staff.
Dictation Template
State: "This is Dr...."
Patient Name:
A#
Log #
ADMITTED TO:
Date of Service
BRIEF SUMMARY OF PREHOSPITAL CARE
HISTORY
PHYSICAL EXAM (include VS and SaO2)
DATA (lab, x-ray, EKG, ultrasound, etc.)
DIAGNOSIS (include differential)
INTERVENTION AND MANAGEMENT
PROCEDURE NOTE
COURSE IN THE ED
CONSULTATIONS
PATIENT CONDITION
DISCUSSION WITH FAMILY/RELATIVES
FINAL DIAGNOSIS
REPEAT YOUR NAME AND ADD THE NAME OF YOUR STAFF FOR CO-SIGNATURE