Nursing Process in ER Documentation

  1. 0
    I'd like to hear from other ER nurses about how they ensure their documentation reflects the nursing process. In my research, it seems to be the best way to show that I have meet the "standard of care" and will help protect me in any future malpractice lawsuits.
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  4. 0
    ADPIE - assessment, diagnosis, plan, intervention, evaluation. We have an initial systems flow sheet for assessment, and then a narrative note. On the narrative note, you address the elements of the nursing process. For example, this is exactly what my documentation on the narrative would look like for a patient having an asthma attack:

    1201: Nsg dx - impaired gas exchange. Pt to rm 4 by wheelchair. C/o sudden onset extreme SOB. Able to speak 2-3 words at a time. Room air SpO2 88%. Audible exp wheeze. Placed on cardiac monitor and O2 via NRB at 15 Lpm. MD aware of pt. arrival.
    1203: MD in to examine pt. SpO2 increased to 95%. Aerosol treatment ordered.
    1204: Albuterol/atrovent via neb. Portable CXR done.
    1208: SpO2 maintained at 96-98%

    And so on. So it addressed assessment and diagnosis, the plan is obvious, implementation steps, and evaluation (ongoing assessment).
  5. 0
    Whatever happened to Airway Breathing and Circulation?


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