ER Nursing notes tips

Posted

Hey everyone!

I'm a new ER nurse (new grad) and I was wondering what you all absolutely include in your initial notes when you see someone as a new patient and then your follow-up notes what you like to include, or are sure to include. I think I'm getting better at writing notes but I was looking for different things that you all may do to protect yourself while providing good patient info/updates. Im in a very busy ER so Im looking for a way to write awesome notes while also being time conscious. Thanks in advance!

WKShadowNP, DNP, APRN

Specializes in Hospital medicine; NP precepting; staff education. Has 21 years experience. 1 Article; 2,077 Posts

My initial note is usually like an intake note: "Pt. presents to ED3 with c/o SOBX 4 days." and then I add a bit about their appearance and vitals and what I did. Most of the rest of my documentation is "clicks" which verifies I did specific interventions or includes documentation screens for IV sites or focused assessments.

As the care progresses I update the vital signs, note any changes. Much shorter notes than on the floor because the "clicks" take care of it. I only write very long notes with there is something noteworthy. Charting by exception.

Bobjohnny

Specializes in ER. 99 Posts

Only applicable to when somebody leaves. But, if someone leaves AMA(Against Medical Advice) make sure that you always write that disability, loss of lifestyle and death are risks of doing so. Believe me, write this if it is a hangnail, a stubbed toe, anything. I've had a patient leave AMA and expire within several hours of doing so. If possible have a second witness to the patient signing AMA paperwork, and document it.

Edited by Bobjohnny
grammatical error