ER Charting

  1. Hello everyone,

    I am considering revising our ER charting sheet. Currently we use a one page chart that I think is pretty standard. We always run out of room for nursing charting on a complicated assessment, and there is really no good place to document interventions other than medication. We currently attach a nurse's note--or if I know the doctor is going to dictate instead of write, I use part of the doctor's note.

    Anyhoo, what I am looking for is suggestions, or what everyone else is using. I don't really know where to look for some examples, most of the ER's around here are using forms that are pretty similar.

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    Joined: Mar '02; Posts: 371; Likes: 10


  3. by   OKNURSE
    I have currently been assigned (by the Medical Staff) the duty of obtaining examples of ER records from other facilities. Our record, as well, lacks adequate space for nursing documentation and we frequently have to attach a nurse's note for narrative documentation. I have several examples that are good and much more inclusive than what we are currenltly using. I am also the Trauma registrar at our facility, and if I could suggest, if you don't already have it on your ER records, you should incorporate a small area to document the Glascow Coma Score and the RTS, and, in addition a place for the Pediatric Trauma score (when applicable), for this is a required field when reporting major traumas This, however, may not be required in your state.. Also, I have several examples that include a drawing of the body, on which, the physicians can draw/mark areas of uinjury/abrasions/lacerations, etc.