JCAHO reqs for ER assessment??

Dixielee, BSN, RN · Oct 18, 2004

I don't know what the JACHO regs require, but I do like the form we use. I don't have it in front of me, but it is a 2 page, triplicate form that moves fast for quick ER assessment. It starts with time, date and signature of nurse doing assessment. Then moves from head to toe with checklists. Resp, cardiac, neuro, musculoskeletal etc. Ends with peds. Each has a checklist of pertinent info and a box for free text to the side. There are 2 columns to the right of that for updates Q2 hours. The second page has a place for additional notes, meds, IV's, labs etc. The pages are connected and easy to use. I will be glad to fax you one if you give me a fax number. Just PM me, if you would like one. You may be able to get several facilities to fax you theirs and you can tweek one to fit your facility.

BTW, I love your section of the world, also has the distinction of the smallest police station, if I recall. My in laws lived in Panacea....just down the road from you.

rjflyn, ASN, RN · Oct 18, 2004

Now may be the time to go to a computerized system. That is the trend I am seeing over the last couple years. It will also put you ahead of the game as its probalbly going to be required before long by insurance and patients in general. We are a pretty mobile society now days and being able to bring one medical record up online where ever then may be is already being tested in a couple states.

Two systems I have seen computerized are Codonix and Centricity. A good paper system which started as a physican system but now has a nurse system to match is T-system http://www.tsystem.com/ED-Information-System/nurse-charting.asp and its web site states it supports JAHCO standards.

Rj:rolleyes:

Help! I am currently in charge of submitting a new ER assessment sheet.
We have a decent triage/history form, but our assessment is part of an old in-patient admit form from long ago. This is for the MOST remote ER in the state of FL--not kidding, we really have that honor.
Everything is paper, no computer anything. I can't find any JCAHO requirements specific for ER, and need a general form, not focused, it has to cover the teething baby, baker acted psycho and a trauma patient.
Any suggestions would be great, I can always chart more, just need to know what has to be there by LAW(JCAHO)

Dixielee, BSN, RN · Oct 18, 2004

I understand computerized charting is federally mandated to be in place by 2010. At least that is what they are telling us at work. We recently implemented the "Amelior" charting system in our ER. It lasted less than a month, after spending countless thousands on the system. It is NOT user friendly, extremely cumbersome, takes forever to chart basics like vital signs. We had 40% "leave without being seen" becoming the norm. Somedays people were waiting 2-3 hours to be triaged, then who knows how long to get to the back. We know that we will have to have some computerized charting, and maybe even a new and improved Amelior, but my advice is if they offer anyone this system FREE...do not take it. It completely crashed on it's last day, leaving us with 50 patients in the ER, no paper trail and didn't even have the names of the patients in the rooms. What a disaster. I know there are some good systems out there, this just is not one of them!

pkapple · Oct 24, 2004

Thanks. I will try to get a fax# that you can send the form to. I would love even a bad computer system, especially one that tied ancillary depts together. As it is now the only way to view a previous lab value is to manually thumb thru a book, hope the patient is listed(only updated every few months) physically go to medical records, pull the chart and pray the labs were filed. Oh, I am the only RN in the ER, and have an LPN to work with if I am lucky!

I was sure hoping some one could direct me to a list of JCAHO reqs tho, cause we all know change is a difficult thing!!

veetach · Oct 25, 2004

Thanks. I will try to get a fax# that you can send the form to. I would love even a bad computer system, especially one that tied ancillary depts together. As it is now the only way to view a previous lab value is to manually thumb thru a book, hope the patient is listed(only updated every few months) physically go to medical records, pull the chart and pray the labs were filed. Oh, I am the only RN in the ER, and have an LPN to work with if I am lucky!
I was sure hoping some one could direct me to a list of JCAHO reqs tho, cause we all know change is a difficult thing!!

I am on an implementation team for a new computer program in our ED. Our hospital is currently on the Meditech system hospital wide and our program is called the "EDM". It is fabulous. Very user friendly and has already been proven to help speed up documentation in the ER. We are currently building assessments in the program.

I am not aware of any JHAHO requirements as far as assessments go, good luck in your search. :)

pkapple · Oct 26, 2004

Thanks All

I emailed JCAHO directly tonight--scarry thought, will await reply.

reigh · Apr 6, 2011

I am interested in any old paper forms nurses used to use for assessment for a ongoing study. I know this post is old from 2004 but if anyone has any sheets like the one reference in the beginning that covers all in triplicate that would be wonderful. I was also hoping to maybe someone has old focused assessment sheets to for areas of concern that compliment a comprehensive triage form.