Going to ER from ICU. Help!

psu_213, BSN, RN · Dec 29, 2012

I recently accepted an ER position, I did CVICU previously. I know that in the ED the assessements are more focused. However, during my share day the nurses would document a full-head to toe without actually doing one. For example: a nurse would say palpable pulses but never actually palpalted the pulses.
Is this common practice in the ED? I understand not checking pulses for a sore throat, however I just question the documentation aspect of it.
The flow sheet for the assessment is very thorough and I fear if I did do a full head to toe for every patient, I'll be way behind.
Any tips, advice, or suggestions will be greatly appreciated.
BTW- I'll be doing nights 7p-7a.

The way our charting works: on our assessment forms on the EMR, for each system you can click "WNL" (within normal limits) or you can click "NA." In a box next to that, you can free text for each system the abnormals. If you click WNL, you do not have to type anything in the free text area. The assessment should be focused. For example, if someone comes in with a twisted ankle, you would "NA" the GI part the assessment. Some nurses click WNL for every system....they had to be reminded that WNL does not stand for "we never looked." In other words, focused assessment and don't make up what you did not actually observe.

I'm not sure how the system works in your ER, but if it makes you chart the presence of the pulses, you darn well better feel them before you chart "pulses palpable."

nurseprnRN, BSN, RN · Dec 29, 2012

Learn to do it faster, or assess several things at once (like facial symmetry while observing the patient talk, or extremity strength while helping him move in the bed). You will. Actually, you must: I can't tell you how often I see an ER flow sheet that "documents" things that cannot possibly have occurred. Conversely, I have seen cases saved by nursing documentation of, say, the patient's own words at presentation, like, "I have a sore throat and a rushing sound in my right ear when I bend over." Since the physician or PA never addressed the ear, the intracranial pathology was missed, and then ... But the nurses are off the hook because they did mention it; it's the MD or PA that didn't read their documentation that's in the soup.

You never, never know when that foolish little minor foot injury will balloon into a huge lawsuit five or six years down the line (and oh, my, the stories I wish I could share) but believe me, you do NOT want to be part of them because your assessments were bogus. Never, never, never chart pulses present (or anything else) that you didn't really assess.

OnlybyHisgraceRN, ASN, RN · Dec 30, 2012

Thank you both for the advice. Grntea, I've been in nursing for 6 years and I always fear the day when I'm on the beach in the bahamas and get the dreaded phone call from a lawyer regarding a nursing note from 5 years ago. To prevent that from happening I'm very cautious with my documentation.

Anna Flaxis, BSN, RN · Dec 30, 2012

I will only document on assessment findings that I actually did, and yes, ED assessments are focused on the chief complaint in my neck of the woods.

Our documentation consists of paper flow sheets with narrative notes, so for example if a person came in with new onset leg pain, I might document a narrative note like: 1045 to room 12 via WC, c/o "burning" RLE pain, onset at 0900 today while seated at the kitchen table. Able to transfer with assistance from WC to stretcher. RLE pale, cold to touch, pedal pulse absent. Dr. Awesome notified of assessment findings and consulted for pain control, orders received and implemented. 1055 Dr. Awesome at bedside.

Since your flow sheets do require documentation on every system, then I would say that you do need to do a full head to toe. It sounds like the documentation is cumbersome and nurses are in the habit of taking shortcuts. I would feel very uncomfortable charting on an assessment finding that I didn't actually do.

RNperdiem, RN · Dec 30, 2012

ICU nursing has an underlying structure.

You take report on your 1 or 2 patients, assessments, turn Q2 hrs, first rounds of meds, talk with MD on rounds, next set of vitals...

Of course the unexpected situations pop up, but there is an underlying routine so you can do more planning of your day.

Do you like to plan ahead? ED does not have the same ability to plan; you need to be able to "hang loose" and take things as they come and be able to deal with change quickly.

Columnist · Dec 30, 2012

Moved to Emergency Nursing for more response.

OnlybyHisgraceRN, ASN, RN · Dec 30, 2012

ICU nursing has an underlying structure.
You take report on your 1 or 2 patients, assessments, turn Q2 hrs, first rounds of meds, talk with MD on rounds, next set of vitals...
Of course the unexpected situations pop up, but there is an underlying routine so you can do more planning of your day.
Do you like to plan ahead? ED does not have the same ability to plan; you need to be able to "hang loose" and take things as they come and be able to deal with change quickly.

I was able to do a share day and you are 100 percent correct. I guess, I'll found out soon. I know in my heart that for me working in the ED is a huge risk. I already know myself and personality type. However, I have bills and I need a job. I went on 5 interviews and this was the one offered and that was the best fit so far as commute.

hiddencatRN, BSN, RN · Dec 31, 2012

I will only document on assessment findings that I actually did, and yes, ED assessments are focused on the chief complaint in my neck of the woods.Our documentation consists of paper flow sheets with narrative notes, so for example if a person came in with new onset leg pain, I might document a narrative note like: 1045 to room 12 via WC, c/o "burning" RLE pain, onset at 0900 today while seated at the kitchen table. Able to transfer with assistance from WC to stretcher. RLE pale, cold to touch, pedal pulse absent. Dr. Awesome notified of assessment findings and consulted for pain control, orders received and implemented. 1055 Dr. Awesome at bedside.Since your flow sheets do require documentation on every system, then I would say that you do need to do a full head to toe. It sounds like the documentation is cumbersome and nurses are in the habit of taking shortcuts. I would feel very uncomfortable charting on an assessment finding that I didn't actually do.

Dr. Awesome saw the patient within 10 minutes? That IS pretty awesome! To OP: I chart what I do. Our computer flow sheets have places for assessment and if I don't do it I leave it blank.

Vishwamitr · Dec 31, 2012

17 years ago, our nursing instructor sent nursing students into 2 separate patient's room; one student at a time, to "assess" pedal pulses of one and "measure the BP" of the other patient. We had a gag-order not to discuss our findings.

4 students were rusticated from the nursing program instantly because 2 students reported pedal pulses and 2 reported their blood-pressure "findings" with numerals.

Turned out, the former patient had bilateral BKA, and the latter had already died just a while ago.

I never document what I didn't assess or see for myself.

Sugarcoma, RN · Dec 31, 2012

I think your ICU background will serve you well in the respect that you will be used to things changing quickly and having to pick up on that and act fast. I think ER nursing is multitasking to the nth degree. There is nothing more impressive to me than watching a good ER nurse do her/his thing. Congrats on your new job. I hope you love it!!!!

OnlybyHisgraceRN, ASN, RN · Dec 31, 2012

I think your ICU background will serve you well in the respect that you will be used to things changing quickly and having to pick up on that and act fast. I think ER nursing is multitasking to the nth degree. There is nothing more impressive to me than watching a good ER nurse do her/his thing. Congrats on your new job. I hope you love it!!!!

Thanks.