ER MD documentation and triage??

[rn paramedic]

Hi,

I haven't used this site since I was in RN school. So glad to have found it again! Hope someone can offer advice!

I have been asked to help with some of the issues in my ER. We have no unit manager and are not going to get one anytime soon. However someone has to try and improve a few things, and against better judgment I have agreed to try and help. We need some sort of system for MD documentation. Now we are currently using basic hand written charting on the part of the MD. Doing this has been a problem because some of them are not documenting correctly and we are not getting reimbursements. I was wondering what other ERs use. I here the t-sheets are great, but currently we are unable to purchase anything. Is there anything out there free or very little cost?

Also it seems our triage system is very out of date and I was going to try to implement ESI. Does anyone have any experience with this, if so how is it working? We are a very small rural hospital, do you think it would work in that type of hospital? If you do not use ESI or a 5 level triage system what are you using and how is it working for you??

Thanks for any advice!!!!

[nuangel1, BSN, RN]

we currently use pre printed t sheets .these are pretty detailed and are updated periodically by our med director -attending ed md,he keeps up very well with the documentation.our secretaries actually review and have a checkoff list ,done on all charts after pt is d/c.our director is actually now using and trialing a computerized version of above and dictating the the t sheet .then this gets printed out for the pts medical record.

[piratern]

Preprinted t Sheets work well for a paper system. Docs seem to like them pretty well. The nurses sheets are good as well. They'll do the ticket for you until you are forced to go to electronic documentation. As far as the ESI system. I've implemented it twice in two different systems. (I am a manager). Both went well. Go to the AHRQ website and you will find FREE DVDs and booklets and everything you need to implement this, teach this and create competencies. Kudos to you for being a leader in the absence of a manager. Leaders are what's needed everyday and rarely carry the "manager" title.