Documentation

Our ED just uses the narrative for basic care procedures and other comments we want to make on the patient. We also chart by exception, but I really can't think of anything else. We have most of the patient information on the computer and it prints out everything, except our assessments.

I work as a tech in a very small ED (8 bed). We use T-sheets. Front is assessment, back is procedures done to the patient while in our care. The Drs. have theirs, we (the nurses and techs) have another. Procedures are a time and initials, everything else is just check what applies. We have a small space for any narative info that applies to the patient (chart by exception there). We have space for vitals while in care and another space for vitals on discharge. Charting really doesn't take that much time, if you just make sure to time/initial what was done when you do it.

We have no computers in the ED so everything we do is paper.

i'm currently in a 17 bed ER and all our documentation is computerized. it can take a little more time going from screen to screen or section to section than just writing it on a chart. the plus side is that i dont waste a ton of time trying to remember where i left the chart or where the doctor put it. eliminates the need to ask everyone what some illegible scribble is suppose to mean too. (my last job i suggested getting GPS for the docs so i could track them down easier...)

Documentation is such an important part of the ED RN's role that I wouldnt want to shorten it by any means. I am trying to get our nurses to document more bc some charting reads like a scribe just wrote what time evals/tests/ procedures/meds were done without any assessments or outcomes!

Are you spending too much time doing non-critical things that if delegated could leave you more time for pt care and documenation?

Do you have techs and LPNs?

Hi everyone! This is my first thread, so bear with me! I'm an ER nurse in a 12 bed ER and we are trying to find ways to spend more time with hands on pt care and less time with documentation. Any suggestions to shorten documentation? We already do charting by exception with a flow sheet for our assessments, but does anyone use a flow sheet for checking on pts, for basic care or anything of that nature? If you use this and have a comments, or have any suggestions, they would be greatly appreciated! Thanks :)

ER charting is so important to the care of the patient.

Often the nurse who gives report is not the one who cared for the patient.

I rely on the charting for everthing from Hx, allergies, VS, assessments, and treatments done (and what I still need to do.)

Essential for an ICU or floor nurse.