Need Documentation tips-ED new grad

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Specializes in Tele, ED/Pediatrics, CCU/MICU.

I am a new graduate in a 30 bed ED. I completed my senior preceptorship there (for a little over 3 months) and am now starting a 6 month orientation as a new graduate. Each week, we have 2 class days and spend the rest of the time with a preceptor to get us to 40 hours/wk.

I am finding that my biggest worry is that I am not documenting right.

I'd like to know the best and most efficient way to document in a way that is both legally satisfying but not overkill.

My first preceptor was one that made me write "practice notes" before every single note. That was TOO much supervision. My new preceptor for the new grad program writes notes that are shorter, less detailed, and not as complete. I'm sure this is because she has been a nurse for 25 years and she's over it. :) haha

I need a HAPPY MEDIUM!

Any suggestions?!

-M

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Specializes in SICU, EMS, Home Health, School Nursing.

I don't work in the ED, but I do work in the ICU and we tend to get direct admits. Make sure you chart every wound, the size, color, etc. that is very important, because that way they can't come back and accuse the hospital of giving it to them.

Always chart what you do and the affect. Like if your patient is agitated and you give them ativan, make sure you chart the amount, route, reason and affect Heres how I chart giving meds..."Pt noted to be agitated, attempting to sit up in bed and pull against restraints. Pt. medicated with 2mg Ativan IVP. Will continue to monitor." Then after a certain amount of time I chart if the patient is resting quietly or if they remains restless.

Where you can, try to chart the patients exact words... like if you have a patient that is threatening you chart Pt said "I am going to hit you(their exact words)" then chart what you did about it.

Chart when you call the doctor, or talk to them, what you tell them and what they say (to a point) For example I will chart every time I page a doctor, how I paged them, and why, then when they call me back I chart what I tell them and if I received orders or not. Ex. "0140 Paged Dr. Smith via office answering service" "0145 Paged Dr. Smith via overhead pager" "0157 Dr. Smith returned call, updated on HR 220, BP 90/50, Pt diaphoretic and pale, attempted to have patient vagal down with no results. Dr. Smith states he is "on his way"" That way you have a way to prove what you did, etc.

My theory is that yes, there is overkill, but I would much rather be charting too much than not enough. Someday if I get pulled into court I want to be able to read back through my charting and know exactly what was going on. I don't want to have to sit there and try to think of what was happening.

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Specializes in Critical Care, Emergency, Education, Informatics.

A comment here from the worlds worst documenter.

You chart in a way so that anyone who looks at the chart, 1,2,10 years whatever from now will know what's happened to that patient. Yes you can document to much. I know a nurse that documents what clothes the patient is wearing, not that is way to much.

My brain processes documentation like this, I write what I see, what I did and why, and what the response was. And I document every assessment.

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Specializes in Emergency.

Here's some tips:

  • Try to chart what the patient says, especially when you first assess them (ie Pt c/o chest pain that "feels like bricks on my chest")
  • If you discuss something with the MD, write that you consulted with them and what the outcome was (ie Pt c/o pain, 10/10 - MD aware, orders received....or, Pt c/o pain, 10/10 - MD aware, no orders received)
  • Chart alot on drunk patients or patients that are at risk for falls (ie Pt in bed, watching TV; curtain open in room, fall precautions in place; pt aware they must use call light before getting out of bed. Family at bedside, room lights on, call light in reach - will continue to monitor)
  • If a patient has been waiting for a bit and is upset because they havent seen the doc yet, chart it (ie Pt states "when am I going to see a doctor, I've been here forever". Pt reassured of treatment, awaiting MD exam). Actually, "pt reassured of treatment" is my favorite thing to write!
  • After completing the initial assessment (we use charting by exception), I write in the nursing notes "RN assessed, pt gowned and on continuous cardiac monitoring. EKG completed and shown to MD. BP cycling every 15 minutes. Will continue to monitor" (depending on what is going on with the patient, I will just write "RN assessed", or will go into into great detail like I did above).
  • If you assist with a pelvic exam, chart that you did it and the patient tolerated the procedure with no signs of discomfort (ie "RN assisted MD with pelvic exam; pt tolerated well, cultures sent to lab").
  • When discharging a patient, I write "Pt discharged home, instructions given; pt verbalized understanding of discharge instructions. IV removed without difficulty, no signs of discomfort or irritation. Pt will return to ED if signs/symptoms change or worsen".
  • When admitting a patient, I write "RN called report to Mary RN, charge RN on 4th floor", or "Report faxed to 4th floor". When they go up, I chart "pt admitted to 4th floor; IV capped, site c/d/i; pt on monitor, accompanied by ACLS RN and EDT"

I'll stop now...hope it helps.

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Specializes in Tele, ED/Pediatrics, CCU/MICU.

That is PERFECT! Exactly what I needed to hear. Thank you!!

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Specializes in Emergency.

These are awesome tips. Even to some of us that are not brand new to the ER.

There is one that I learned is that when you are documenting who you gave report to or what md you reported to make sure to include a last name.

Thanks

(I'll gladly take anymore that you have)

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Specializes in critical care,flight nursing.

Well I don't know if I chart the best way but here my 2 tricks. At the beginning of each shift I take a "picture" of my patient. I assess each system and spend more time on the system is in the ER for. For example, Come with N/V and LLQ pain:

" alert. pink, dry warm skin. 2/2 L radial regular pulse. No distress. None labored breathing. C/o Nausea. no vomiting. Normal BSX4.abd soft. Tenderness with no guarding with light palpation LLQ. Pain 4/10 describe as sharp increase with mvt . Some relief with medication. No BM. State last voided at 1300. denies any other complaint.Ns lock patent.Waiting for blood result. will continue to monitor."

If they have a relevant medical HX( asthma, diabetes, HTN, etc) I spend some time on that. For example I would auscultate an asthmatic. Then I chart every hour( if possible) and concentrate on breathing, skin, neuro, system in trouble and plan.For example an hour later:

" Alert.pink. mild distress. None labored breathing. State pain increase to 7/10. No vomiting. Morphine 5 mg Iv. will reassess pain and continue to monitor".

So right at the beginning it kind give me a picture of the patient at that point in time. I always ask myself that question when I write a note:" If i go to court in 3 years, what would I like to be able to remember?". Cause mostly that's the main reason we chart. So imagine yourself answering a question to a lawyer and you only have your note in front of you. Write to yourself the things you would like to know. I never had to go to court. But I feel when I do a follow up like that with my note, I would be able to answer. Also, it's a reminder to verify for those thing. for example if the patient would be pale now, I would intervene. I would look at his pulse, verify his vitals, etc. Hope I help!

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Just think about what questions a lawyer would be asking if a lawsuit was to happen.....

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Specializes in Emergency.

For the Critical patients, I was told at the beginning of the shift to make sure I chart everything, so I have my own baseline. Start at the head to make it easy, and work your way down, that way you don't miss any body systems from jumping around. Neuro -> Resp -> Circulatory -> GI -> GU -> Musclo-Skeletal.

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Specializes in Emergency, Trauma.

Been in the ER six years; now in a supervisory position and see all the bad outcomes/pt concerns/case reviews that I never really saw when I was on the floor...so things that will protect you when documenting...

For ANY significant abnormal assessment finding or lab result, document what you DID about it.

Know your ED's policy re: frequency of repeat assessments; ours is to reassess and document chief complaint with VS q 2 hours. If a pt goes bad, you need to be able to show it didn't occur because you weren't assessing.

Document pain level before and after pain meds...huge JCAHO thing and a big complaint from our ED docs when its not done.

Document IV site assessments when giving vesicants; Dilantin, Bicarb, Phenergan, pressors, etc.

With AMAs, document pts state of mind (i.e., clear speech and mentation) and understanding of risks of leaving.

Document name of driver when pt leaving after getting a med that affects CNS. Also, that you have educated re: no driving.

When removing pt belongings (esp jewelry and dentures) or transferring pt to floor, document what they have with them. Better yet, lock it in the safe. It is amazing how many pts claim we've lost their wallets stuffed with cash or diamond earrings.

Document when you notify the MD of any critical lab values...another JCAHO AND CYA thing.

These are issues that FREQUENTLY come up and documentation is the only way to cover yourself.

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Specializes in Emergency.

Excellent tips. Thank you so much :nuke:

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