[lalaxton]

Any ER NP's out there willing to share any documentation templates that you use in your facility?? We have just hired our first NP's in the ER and the forms the docs are using are really not very adequate.

Thanks!!

[cgfnp]

Originally Posted by lalaxton

Any ER NP's out there willing to share any documentation templates that you use in your facility?? We have just hired our first NP's in the ER and the forms the docs are using are really not very adequate.

Thanks!!

When I came to a rural hosp I helped change the ED documentation to T-systems. Before, it was basically a blank progress note. Needless to say, the documentation was horrid before. It also helps upcode for better reimbursement on the ones who actually do have insurance.

[DaisyRN, ACNP]

In our ED, we have been using the T-system as well. It is VERY simplistic... and it also works for the nurses. Both the nurses and the providers have their own t-sheet for a certain complaint, i.e. upper respiratory or chest pain. VERY easy to use. We are about to go to Cerner electronic system though... not very excited about this. I've used electronic systems before, but this one is one that an ED MD we work with used while she was in medical school... and she's been out of school a long time.

[lalaxton]

Unfortunately the MD's here are very reluctant to go with any electronic system. I have seen the T-system but it is doubtful the hospital will cough up the $$ to purchase. Our problem is that the new NP's are also new grads and are having trouble with organizing their thoughts on paper (and driving their physician collaborators nuts, hehe) and need some way to document in such a way that will make it easy for them to get organized and be easy for the docs to see what their clinical reasoning was. Am I making sense??
Maybe I'm looking for something people used in their NP training program to help them focus an exam?

[cgfnp]

Originally Posted by lalaxton

Unfortunately the MD's here are very reluctant to go with any electronic system. I have seen the T-system but it is doubtful the hospital will cough up the $$ to purchase. Our problem is that the new NP's are also new grads and are having trouble with organizing their thoughts on paper (and driving their physician collaborators nuts, hehe) and need some way to document in such a way that will make it easy for them to get organized and be easy for the docs to see what their clinical reasoning was. Am I making sense??
Maybe I'm looking for something people used in their NP training program to help them focus an exam?

You can make your own check off sheet for the most common complaints then make a general SOAP based sheet for the rest. That's the premise of T-Systems anyway.

[tiredfeetED]

I have a question, why can't the ER NP use the same form that the MD use?

[akoster]

I work at an np in an er and also use the T system but if you can't get one then maybe it would be helpful for the collaborating physician come up with a format that he want to see. If he is frustrated she won't know how to fix it the way he wants. Each physician can have their own quirks. I know one that superglued the phone in a certain place on the desk so it isn't moved. Crazy.

[DaisyRN, ACNP]

Originally Posted by tiredfeetED

I have a question, why can't the ER NP use the same form that the MD use?

Hey there, just wanted to put in my two cents. At the hospital I work in, the PAs use the same T-sheets as the MDs. There's no difference in their charting, except for the fact that if the PA sees the patient, theres a place on the back where the MD will say, "Have discussed and agree with PA" or similar.

[npingeorgia]

Hi
Just wanted to add that in the ER that I work in the NP's and the PA's use the same sheets that the MD uses. We are currently using the t system. There is a place for the midlevel to sign as well as the MD.
Works well for us.