DEveloping a documentation tool

  1. Our ED (which currently uses Codonix documentation) is switching to a Meditech-- EDM Client Server sourse. This necessitates the development of screens for the ED nursesb to use to document assessment, treatments, procedure assists, etc

    I am currently trying to develop a "Burn Assessment" screen-- more like a burn trauma assessment than a minor-- burn injury

    When you are presented with a burn victim--

    What do YOU look for--so I can make sure I've included as many choices as possible.

    I have: sites involved, thickness, % BSA- (Rule of Nines or Land & Browder), Airway assessment (patent, facial burns, facial swelling, soot), breathing assessment (Clear, stridor, wheezing, decreased) Circulation assessment (normotensive, hypotensive, tachycardic, bradycardic) (these are quick down and dirty rel to the burn pt only-- not the full in depth systems exam that can be found under other main system head-toe assessment), Cause of burn, Urinary output monitoring.

    VS and wt are always documented under their own VS screen, IVs the same, meds will be incorporated via the MAR that the doctors use, as is PAIN

    Am a missing any red flags that I need to put in so nurses (who don't do alot of trauma/burn victims and many of our staff are new nurses in general)) will be aware of what else they need to monitor...

    Any one else using meditech/client server that have these screens developed that I could use as a reference?

    Thank you--
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    About needsmore$

    Joined: Jun '04; Posts: 237; Likes: 52
    Staff Nurse, Educator
    Specialty: emergency nursing-ENPC, CATN, CEN


  3. by   XB9S
    been trying to think of what else you would need which is why I didn't reply straight away. I think my assessment would include:

    Cause of burn, is there any chemical risk to us as carers
    Airway - soot to nose and mouth, voice change, facial burns, neck burns that may cause constriction and suspicious of any flame burn. I would assess for stridor and wheeze here
    Breathing - full respiratory assessment
    Circulation - assessment, observations and any abnormalities, time from burn and % BSA, time from burn, thickness and assessing fluid resuscitation requirement, any renal impairment
    Disability - Glasgow coma score, was there trauma and is there any LOC changes
    Exposure - Full top to toe assessment

    Would also include a nutritional assessment, insert a naso gastric tube and start early feeding