ER Documentation Tips

  1. Anyone have some good tips for good opening ER notes for patient care? Do's and Don't?
    Last edit by Cmmc911 on Feb 18 : Reason: revise
  2. 3 Comments

  3. by   KeeperMom
    Not sure what you are asking exactly. When you are asking for an "opening note" what do you mean?
    Most EMRs have templates or a guide for charting.
    If you are asking about a triage note you should always start with the chief complaint.
    Keep your charting to the point, factual and don't embellish.
  4. by   JKL33
    Are you expected to write some sort of synopsis note regarding the presentation and the initial interventions? We did that eons ago; it's since gone by the wayside because just about anything that could be written in narrative form is already documented elsewhere.
  5. by   Nalon1 RN/EMT-P
    A good tip? Don't write notes unless you must.

    Only notes I write are things like phone numbers of family to call if not on file, a note of something like EKG delayed due to no machine available, CT delayed due to difficulty obtaining labs, telemed physician online, and things like that.
    The last note I wrote was something along the line of "pt refused any pain medication for wrist pain. ER Provider notified". Only reason that was charted was for documentation in case the patient had a long bone fracture and had not been medicated within an hour of arrival.
    Otherwise, there is no "opening" for a note. I just type what I need and am done. Usually 2 or 3 sentences at most. The only real exception is sometimes psych patients get some detailed notes because it does not fit in regular EMR charting,