ED Nursing Notes

[rubyagnes, BSN]

Hi,

I just graduated back in January, and started my first nursing job in a busy ED about two months ago. Things have been going really well, but I've noticed I don't feel very confident in my notes. My school experience didn't really emphasize notes, and the notes we did learn were elaborate "med surg" notes. Many coworkers have said that in the ED they do focused assessments and focused notes, not longer med surg notes. I've gotten a lot of varying feedback from fellow co-workers in regards to note style - some write many one to two sentence notes throughout the patient's care, others write a cumulative note about the patient. I'm trying to find "my style" but I definitely want to do it the right way.

We have many interventions through the meditech program we use, so a lot of what I would write in a note has also been documented within an intervention. I'm hoping to get some more advice as to what I should be including in a note, how often you write notes for a patient in your ED, and the wording/lingo that is used.

I definitely feel that I get hung up on "phrasing" - for instance instead of saying "patient walked to their bed" my preceptor tells me I should say "pt is ambulatory" I definitely don't want to write anything in a note that is compromising to my license, but also want to convey the patients current disposition... Maybe I'm overthinking (I tend to do that) but I feel like note writing varies so much from nurse to nurse that I don't know the "right way" of writing a note, especially in the active ED.

Thanks in advice for any advice you might have.

-T

[Wuzzie]

I definitely feel that I get hung up on "phrasing" - for instance instead of saying "patient walked to their bed" my preceptor tells me I should say "pt is ambulatory" I definitely don't want to write anything in a note that is compromising to my license, but also want to convey the patients current disposition...

Well this could mean that 1. the patient ambulated to the bed or it could mean that 2. somebody walked the patient to their bed but the patient was actually in a wheelchair. Do you see the difference? By saying the patient is ambulatory it describes the patient not the action and tells the reader a host of other things in very few words.

[rubyagnes, BSN]

@wuzzie Yes, I definitely agree and understand the meaning behind the phrasing, that was just an example that came to mind. I'm slowly getting used to writing in this way, but it's a bit of a learning curve and doesn't feel fluid or comfortable just yet. I really wish my school had a documentation class or at least a documentation unit. I'm sure I'll get familiar and more confident with it over time, but at this point it's definitely slowing me down. Thanks for your response!

[Wuzzie]

It will come to you in a very short time. What you'll find is you'll learn to pack as much information in as few words as possible because there simply isn't time for extended notes. Sort of a "just the facts ma'am" approach to charting. I used to chart during codes or other crises on a 2 inch piece of tape stuck to the thigh of my scrub pants!

[psu_213, BSN, RN]

For my notes on a pt., i try to best to write them as they happen and keep them brief--there are sort of like Twitter comments, minus the hostages. "Pt. walked independently to bathroom with a steady gait." "Pt attached to cardiac monitor--NSR on monitor." "Pt. denies pain." Etc. In my assessment and if there is any major event, I would write a longer narrative note. Otherwise, it is brief observations that are relevant to the pt's condition.

[Anna Flaxis, BSN, RN]

I definitely feel that I get hung up on "phrasing" - for instance instead of saying "patient walked to their bed" my preceptor tells me I should say "pt is ambulatory"

Although I'm not certain that it's all that critical whether you use the word "ambulatory" rather than "walking", I tend to use language such as: "Pt ambulatory with steady gait to rm XX", or "Up to BR independently, urine spec collected", or "Ambulatory to BR with stand by assist", simply because "ambulate" is the technically correct term.

I try to avoid language such as "Pt sleeping", "MD aware", "Call light in place, pt knows how to use it", or language that speaks to what others are aware of or know. Instead, I'll state "Resting quietly with eyes closed, respirations even and unlabored", "MD informed", "Call light within reach, pt instructed in use, verbalizes understanding". I don't have any way of knowing what someone else knows or is aware of- it's an assumption. I only know whether I've informed someone of something and what their response was.

When writing a triage note, I try to avoid language such as "Pt hit head on door jamb", instead saying "Pt reports he hit his head on the door jamb". Even better is using quotes, such as Pt states "I hit my head on the door jamb". I don't know that the patient hit his head on the door jamb, I wasn't there. I only know what the patient is telling me.

Make sense?

[cayenne06, MSN, CNM]

I can guarantee I will be thinking in tweets when I chart tomorrow! #VSS

[psu_213, BSN, RN]

I know you meant hashtags but that is one hilarious and unfortunate typo!

Well, there are many people who are hostages to social media.

[akulahawkRN, ADN, RN, EMT-P]

Because you're in the ED, and things generally are under more of a time crunch than perhaps is found on a M/S floor, write your notes as "tweets" that describe what you see or notice about the patient or things you have done that aren't easy to document elsewhere. I'm no fan of "double" documentation, so I try to avoid this but sometimes this isn't exactly avoidable so I minimize this whenever I can. For instance while doing my systems assessments, I almost always check the "WDL" box along with the "other" box at the bottom and type "except as noted below" and I'll check the appropriate boxes in that system and I'll use "other" boxes as necessary to fill-in whatever I find.

One other problem/issue with computer charting is that sometimes there are many places to document some finding in the chart and what you document doesn't populate across to other areas of the chart that also show that same data. Unfortunately this means if someone's checking my documentation I get asked about whether or not I documented something because it wasn't documented in a place where that person would have documented it.

Over the years, when I worked in the field, I used a fairly basic template of what to write. Yes, these were all written reports. What I did was simply "plug in" the relevant information into my template and the narrative would almost fill itself in quickly.

Currently I do charting by exception in the ED that I work in but there are times I do more of a narrative-style charting. That's primarily done in the triage notes but there are other situations that popup where I need to be a bit more descriptive. Another unfortunate thing is that the clinical note boxes are limited in length so I can't be as verbose as I would sometimes like. Brevity is still key in the ED!

[Birry]

Most of my charting is by exception, but the notes I most frequently make are "Dr xxxx at bedside," "pt up to bathroom without assist, ambulated with steady gait," and anything that isn't covered in my EPIC click boxes.

When I do get very specific is when I notice someone acting hostile or displeased with things out of my control. Those are usually the complainers and potential litigants, so I try to provide as much detail as I can. This is where direct quotes are your best friend. If someone requires physical or chemical complaints or is on a hold, every interaction and observation of behavior outside the normal realm of expectation gets described in a note. I hate the CYA mentality, but my license is worth taking a minute to accurately describe a situation which may be audited or called into question later. Don't be afraid to have someone else look over your note, or even have them enter their own.

[Roy Fokker, BSN, RN]

Technically, per management, we're not supposed to have ANY notes in Triage. Narrative documentation is to be done by the Primary Nurse. And even there, they discourage us from being "too wordy" - rationale being that the more info you have on the chart, the more a potential lawyer can use as ammo in a lawsuit. They want us to stick with the pre-designed click-boxes as much as possible.

Me? It is a case by case basis. With most patients, I feel comfortable enough to get by with the click boxes. Some folks though - if they're really really sick (because their condition isn't covered by click boxes) or "difficult/potentially sue happy/drug seeking", I will use the Nurses Notes to cover my butt to the max. Especially when it comes to stuff like "ERMD made aware of pts VS prior to discharge" or "pt. still awaiting eval by ERMD" (if they've been waiting 9 hours to be seen) etc.

anything that isn't covered in my EPIC click boxes.

We use IBEX now but are supposedly soon switching to EPIC.

When I do get very specific is when I notice someone acting hostile or displeased with things out of my control. Those are usually the complainers and potential litigants, so I try to provide as much detail as I can. This is where direct quotes are your best friend. If someone requires physical or chemical complaints or is on a hold, every interaction and observation of behavior outside the normal realm of expectation gets described in a note. I hate the CYA mentality, but my license is worth taking a minute to accurately describe a situation which may be audited or called into question later. Don't be afraid to have someone else look over your note, or even have them enter their own.

Ditto!

cheers,