ER Documentations

  1. During our JACHO survey, we were sited for not using Pain Management scale on our assessment forms. We were aware that we needed to update these forms. The DON and I want to have an assessment form according to complaint. The ER physicians use something like this.
    Our documentation in the ER at the present is greatly needed for inprovement. We are a small rural hospital that sees about 750 patients a month. I would like to hear what forms or documentations systems other ER's uses and if anyone uses the Complaint oriented templates.

    Thanks,
    Lisa
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  2. 6 Comments

  3. by   denicke
    Lisa, I am part owner of a company (4 ED nurses) who have developed complaint specific templates for documentation specific to ED's. One of our clients recently had a very successful JCAHO survey. I know this is not the place to advertise, but I was unable to email you. If you are interested, please email me and I will give you our website address. Thanks, Debbie
  4. by   Irish Lass
    I am the Administrative Director in an ED that sees about 55,000. I have also been in the trenches for well over 20 years.
    We recently began using ED nursing specific documentation. See it at: www.endsllc.com

    It is complaint specific, very thorough. I showed it to the JCAHO surveyor prior to using and he was impressed. It meets their pain monitoring criteria. It is also easy to use. The worst adjustment was not writing lines and lines of narrative assessment. (and the down side of that is?)

    As an additional benefit to great documentation, we increased our billing per patient over $50 because the documentation allowed us to catch charges the nurse may have forgotten. With reimbursement such as it is, every little bit helps!

    I know where Eatonton is - I used to live in Augusta. Please feel free to contact me if you want to know more about our ED selecting this product.

    Good Luck!
  5. by   leachnh
    is it possible to get a look at a sample form dealing with the assessment of neck/back pain for e.d. nurses?
  6. by   TraumaLPN
    To correctly document pain you must use a pain scale during your initial documentation and after every intervention. How else will you prove that you treated the patient for his complaint of pain. The 0-10 pain scale is easy to use. {0 being no pain and 10 being the worst pain you've ever had}
  7. by   CrohnieToo
    Our hospital and ER use the 0-5 Pain Scale and I hate it. 0-10 Pain Scale works best for me as a patient. I've never hit a 10 (thank goodness) but I did once hit a 9 when I encountered TWO dry sockets and didn't have enough sense to call the dentist over the weekend for some relief. DUMB! Having never encountered severe burns, the kind that require hospitalization and round the clock sedation, I've figured them as a 10. Never having encountered a severe kidney problem or kidney surgery I've rated that pain an 8. I did encounter a 7 when I obstructed and perforated from Crohn's disease in the small intestine. 1 just means I'm "aware" of the area. 2 means, doggone it, that's irritating! 3 means, dang this is getting uncomfortable. 4-6 are the ones that I'm hitting the Tylenol or by a 6 I'm thinking of the doctor, if he's in, or ER. I've never been able to condense those 0-10s to a 0-5.
  8. by   TraumaLPN
    On the best pain scale I've ever seen (on the hyster-sister's website) with a 10 rating you are passing out from pain. Most of the pts. I see in my ER rate their pain 10, while they are sitting there smiling, eating Doritos and coke.

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