Charting during traumas

[nurseladyk]

I am wondering how you go about charting thoroughly during a trauma or with a critical patient when you are the primary nurse for the patient. I work in a smallish ED (14 bed, often filled to capacity) and at most we are staffed with 4 RN's with a charge and no tech. Often if a trauma comes in, the nurse who takes it already has three other patients. We will all band together and help, but sometimes you are on your own doing all of the tasks that come along with a critical patient, along with the charting. We are currently paper charting. I often feel like once the patient gets stabilized, I am left charting on all the events that have happened since arrival and it is a little overwhelming. It is easy to make notations of times of med administrations, and that can help put the timeline together of charting, along with looking back at the vitals. Of course in a more ideal situation, someone could be charting as someone else is "doing". This pretty much never happens. I feel like the patient is ready to head off to ICU and I haven't written anything down other than checking off what meds I have given and at what time! Any suggestions?

[FF-PHRN]

That sounds pretty typical for my hospital and how we handle big traumas. The house supervisor comes down, SOMETIMES, when something is called overhead such as a "level1 trauma" or "code blue". the supervisor will write stuff as it happens on the dry erase board to be charted later. Maybe one of your other staff nurses could be assigned to write, or maybe your charge.

Other than that, I do feel your pain. Pulling everything together to get the chart together as the pt is being shipped off somewhere is pretty typical.

[nurse2033, MSN, RN]

I work at a level two. We have three nurses in a trauma, one is in charge of patient care and charts. An ICU nurse comes down and handles one side of the pt, and another ER nurse handles the other. It works very well. Charting is done on paper with a four page critical care chart.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

I've used the same system from busy level 1 trauma centers to 3 bed rural hospitals. I grab a paper towel from the nearest sink and make notes of highlights, important details with times and any change in patient assesment.

Typical might be "1423 tubed, 7.5, 19 at the teeth. Later that turns into

"1423 hrs; intubated by Dr Ego, #7.5 endotracheal tube, secured with tape, at 19 cm at the teeth, strong and = breath sounds auscultated by MD and RT, procedure accomplished easily. Chest x-ray ordered.

Plus I can fill in a lot of details (monitor rhythm, etc) from memory between the highlights. So much happens in 1 second in a medical or trauma code that I've never found a better way to chart. If anything, I can usually write a small novel in a single code, this way, in retrospect, it's easy to skip the fluff. When the monitors record VS periodically, all the better.

BTW: before somebody calls me on it, yes, I start by noting the time and date when I start the actual charting, sometimes even noting that it as late entry or whatever is appropriate.

I hope this helps. It works for me, and there's always a paper towel dispenser nearby, it seems.

[shoegalRN, RN]

I work in a Level I trauma center and if you are scribe for the event, there is a trauma packet, along with a trauma flowsheet you chart on.

You can take notes on a nursing flowsheet for vitals q 5 minutes. When I'm the scribe, I start with the nursing flowsheet, and then fill in the blanks on the trauma flowsheet that I left out during the event. I am usually charting everything on the nursing flowsheet during the event.

[FancypantsRN]

We have 1 documenter that stands in the room with the computer and does nothing but chart....the documenter is asked to do it as we are waiting for the ambulance to arrive. It does really help, as the primary nurse (like you said) is busy stabilizing and transferring the pt.

[Medic2RN, BSN, RN, EMT-P]

I do what dthfytr does when we are short and there is no additional help. I grab a blank sheet of paper, sometimes I'll tape it quickly to my pants and write as I go.

Not terribly efficient, but when I'm the primary nurse and the recorder and tending to patient care, then I do what I have to do until it can be documented properly. At least I have a timeline to help me.

[crb613, BSN, RN]

We have one person that records everything (usually ERT) while the doc, nursing, RT, lab, xray does their stuff. We also have computer charting so it does not take long to enter your info. If we are not slammed one of us will grab the notes, and chart as much as we can to help out. It works well for us as long as your recorder takes good notes. I have also used paper towel many times as someone else mentioned.....:)

[Ruthfarmer]

Having worked in a tiny rural Critical Access Hospital our small staff would pull together and do whatever was necessary at the time. I have done the temporary paper towel notes lots of times. In a bind during a prolonged code, I have even written all up and down my arm and hand, noting the time line highlights. At a small facility with limited staffing, you don't have the luxury of having someone serve solely as a scribe. Everybody is gloved up and hands-on involved.

[meandragonbrett]

Our trauma rooms are staffed with 3 RNs and a tech. One RN on each side of the stretcher. Depending on which side you are standing on dictates your duties while the patient is down there in the bay. The other RN is the recorder, medication fetcher, etc. The tech's responsibilities is to take the lab tubes, label the specimen, run the lab to our trauma lab, fetch other needed supplies, help transport, etc.

[Medic/Nurse, BSN, RN]

There are some that use trauma flow sheets - or the wipe it up method (paper towel or other "handy" object).

When I do not have a trauma sheet - and worked in a number of places I have some "brains" (key documentation and task sheets) I used to carry when I worked in strange places and was not familiar enough with their "way" to do it as I cared for the patients. I, too, would time my charting vs. times noted for care administered.

I'm guessing that that EMS brings your work to you.

From their sheet is the time arrived and care enroute. Start there - the initial assessment and treatment period should be straightforward - then, then let the auto functions on the monitor help you - VS q 5-15 min, re-assess as necessary - note intervention/response, etc.

Otherwise - make a quick list for you (I had mine on index cards I carried in my pocket if I ever needed them.)

The more you do it - the better you get.

Good Luck.

[nurseladyk]

Thanks for all the input. My department has gotten rid of techs/EMT's and our charge nurse is also our triage nurse, so they help during traumas/STEMI's (we are the STEMI receiving facility for the county)/or other critical situations, but they get called frequently when a new patient comes, the radio goes off, etc. So often we are the only nurse for the patient. And our MD's work in staggering shifts, so often there is one MD for the whole department. We are on our own at the bedside often. I suppose my biggest concern is that often I am busy doing tasks the whole time the patient is in our department and throwing the charting together just before transferring them to either ICU or another facility. I stress that I have forgotten to chart something important or leave out an important part of the assessment and that it will end up biting me in the butt somehow...court or otherwise. It is interesting to me to hear how it is done in larger facilities.