A question for all you ER nurses....

Nurses General Nursing

Published

Specializes in NICU.

I'm just wondering how nurses chart during a crisis situation. When there is a trauma, who keeps up with what is done and not done? And who documents? Is there one person assigned to keep notes of everything that goes on? It just seems like it would be impossible to keep track of everything.

Oh and FYI I'm a medsurg nurse that has been watching too much Trauma: Life in the ER.... :D

Please help me subdue my curiosity!

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I wonder about this too. In my ACLS class they said someone can be the recorder, but I sure don't think that there would be enough personnel to go around to allow for a designated recorder all the time.

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Specializes in Med-Surg.

I've seen every episode of Trauma: Life in the ER! I've wondered the same thing. Sometimes it seems there is someone documenting, but I don't know. I'm anxious to hear the answer.

I wish there were more "Trauma..." shows being made, but they stopped filming them when the HIPAA law was passed.

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Specializes in NICU.

I haven't seen them all yet... But I've seen almost all of them.... Very rarely will one come on that I haven't seen.... stupid HIPAA

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Specializes in ER.

Well, during a critical situation, i.e. code or near code, we do have enough staff that one person usually designates themself to chart what is happening. In really crazy situations, we will sometimes just jot things down on a paper towel, or scrap; like 0345 CPR in progress 0347 Epi 1 amp 0348 atropine 1, etc. The same with traumas. Somehow, it does all just work out!

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Specializes in CCU,ICU,ER retired.

I know I would always check the heart monitor and use that as a basis to write later I also used the bed sheet to write on and corelate that with the monitor

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Specializes in ICU, Education.

I think this brings up a very good point. Documentation differs from nurse to nurse. Some documentation is very thorough, and others is very minimal. The really difficult part is that when you have a crisis, you have little time to document. I have worked many a shift in critical care where I have notes all over paper towels and have to officially chart it all after my shift is over. Sometimes the more critical the patient, the less you have time to chart, which puts us in a sticky spot. I try to take the time. I have often jumped in in the middle of a mess when everyone is helping, and started charting what is happening for the nurse assigned. I always worry that if the **** hits the fan, that I will be called in for deposition, even though it is not my patient... because my name is on the chart. And I know , if push-comes-to-shove I will be called in. So, chart well I guess.

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I have a question too. What do you document in a code situation? What needs to go in that chart? I ask because what if I'm thrown to the wolves during clinicals.

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Specializes in NICU.
I have a question too. What do you document in a code situation? What needs to go in that chart? I ask because what if I'm thrown to the wolves during clinicals.

No one will throw you to the wolves in clinicals and expect you to document a code in an official medical record. Not that you are not capable but that just won't happen. Most likely you'll be ask to observe, be a runner, maybe take turns doing chest compressions, maybe keep notes. But I wouldn't worry about being thrown to the wolves.

During a code on the floor I document what led up to the code, when the MD was called, when the code was called, when the code team arrived, time that CPR was initiated, when the airway was obtained/maintained.... Interventions and response to the intervention. (meds, fluids, central line placement, foley placement) Then the outcome of the code. Was the patient transferred? Did they expire? If so what time? Was family notified? superviser called? ect.

And during a code on the floor we are usually documenting on a paper towel or scrap paper... Usually the documenter is standing in the corner and the nurses working on the patient are yelling out what interventions they are doing....

During a trauma however it just seems it would be impossible to document everything that happens. Esp with the patient being transferred from xray to CT to ultrasound to OR ect...

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

You needn't worry. No prudent nurse would have a student document during a code situation. You might get to do compressions but otherwise your job will be to look, listen, learn and stay out of the way. As far as documentation in the ER. Most ER's have a code/trauma flow sheet which makes it very easy to accurately document what occurs. It often is in checkbox format so there is little actual narrative that needs written. The recorder while seemingly a mundane role is actually very important often keeping track of drug timing and calling out when another round is due, watching for vital sign trends, etc. They are in the "core" group. Many years ago when I was part of a designated trauma team our role was often as the recorder. We had a cart that went right up against the foot of the bed and that was our spot. We were never pushed out of the way because we had to see and hear everything. When I have a critical patient but not a"code" per se I often take a long strip of 2 inch tape and put it on the front of my scrub leg along my thigh. I write things on it from top to bottom which keeps things chronologic. I try not to use paper towels if I can help it as I have spent a few too many hours digging through the trash to find the one I threw away that had the most important info on it.

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Specializes in Flight, ER, Transport, ICU/Critical Care.

FlyinScot gives good advice with the "flow sheet" and the role of the scribe or recorder. The tape trick - putting a 2" strip of tape on the pant leg and write with a sharpie/pen a chronological summary of events is a good one - esp. when flying (sitting). I'd avoid the glove/papertowel methods for the reason noted. I always worried that I'd not get it all - or have a monster resus and 50 feet of strip and think "Where do I start?". It just always kinda works out - A - B - C ... assess, intervention, eval - it just all works. And as a FN my medic partner helped keep team "notes".

As a medic/fn I would hit a "mark" button on the heart monitor when I did "something". Airway/meds - as for putting the patient on the vent - most all equipment is automated to some degree - and as long as the times match (monitor, vent, my chart) the intervention being done - all is well. Even if the times do not match to the second as long as I know the deviation between all timed entries, I can be very accurate.

At one point as a medic - I'd put a recorder in my pocket and have an accurate (and often terrifying, or horrifying or pathetic) audio recording of the "festivities" - the tape erased/destroyed - it was useful and I didn't miss any key documentation issue (I also found it unnecessary) but, I stopped the practice due to liability potential - I'd imagine that folks would not find some of the "contents" therapeutic. Full on resuscitation is not a good spectator sport.

The MAIN thing here is DO THE SAME THINGS the SAME WAY - EVERY TIME. Be methodical and deliberate.

Sharpie markers are your friend.

Examples -

* Ensure that I and my team are safe. (In the ED or the field - safety is Job 1) Identify everyone.

* I assess. Any history/allergies. Note exceptional findings, baseline VS, mechanism of injury issues. Intervene as necessary - 02, access, monitor, etc.

* Advanced airway, management issues (RT, vent mgmt, CT, US, Xray, etc)

* Fluid resus (time and number the IVF bags). Note time on blood bags. Keep everyone on the same page.

* Meds noted - call out med - once in - verbalize med given.

* Trauma resus measures - trending VS, MD's at bedside

I am not sure that any of this helps - but, it may take some time to get your "system" down. Rest assured that you always do - even if the task seems overwhelming or impossible.

Practice SAFE!

;)

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Specializes in ER.

When TSHTF, my documentation technique is the same in the ER as it was on the floor..... whatever I could grab and write on! If you're lucky, there is someone available to document for you, but this is not often the case.

This is really an iffy thing- technically, all charting is supposed to be done in 'real time.' This is not realistic though. It happens rarely- there just isn't enough staff at most hospitals.

It is easier in the ER, in some respects. After a little experience an ER nurse is familiar with how trauma situations will unfold. You know when CT will come, when the doc will probably intubate, etc. Usually the doctor is there right after the pt arrives, so I can use the docs Q&A to fill in what I need. We still use T-sheets and they are designed for fast charting. I :redbeathe T-Sheets! I do worry about when we eventually go to a computer system- I am very computer savvy but most programs are not ideal for the ER. Certainly not any program my little hospital can afford!

Another thing that helped was TNCC. The method of assessment laid out in TNCC really helped me to prioritize when everything is a critical finding and all info is needed stat.

I also use the technology we have to it's full extent. Our trauma room has a moniter that can print VS, tele readings, and '12 lead' printouts, so I usually don't bother to write these down unless one is of great importance or I need to document that I reported it to the doc, changed a drip, etc.

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