I recently accepted an ER position, I did CVICU previously. I know that in the ED the assessements are more focused. However, during my share day the nurses would document a full-head to toe without actually doing one. For example: a nurse would say palpable pulses but never actually palpalted the pulses.
Is this common practice in the ED? I understand not checking pulses for a sore throat, however I just question the documentation aspect of it.
The flow sheet for the assessment is very thorough and I fear if I did do a full head to toe for every patient, I'll be way behind.
Any tips, advice, or suggestions will be greatly appreciated.
BTW- I'll be doing nights 7p-7a.
I will only document on assessment findings that I actually did, and yes, ED assessments are focused on the chief complaint in my neck of the woods.
Our documentation consists of paper flow sheets with narrative notes, so for example if a person came in with new onset leg pain, I might document a narrative note like: 1045 to room 12 via WC, c/o "burning" RLE pain, onset at 0900 today while seated at the kitchen table. Able to transfer with assistance from WC to stretcher. RLE pale, cold to touch, pedal pulse absent. Dr. Awesome notified of assessment findings and consulted for pain control, orders received and implemented. 1055 Dr. Awesome at bedside.
Since your flow sheets do require documentation on every system, then I would say that you do need to do a full head to toe. It sounds like the documentation is cumbersome and nurses are in the habit of taking shortcuts. I would feel very uncomfortable charting on an assessment finding that I didn't actually do.
Last edit by Anna Flaxis on Dec 30, '12