Nursing Process in ER Documentation

[RN4HIRE]

I'd like to hear from other ER nurses about how they ensure their documentation reflects the nursing process. In my research, it seems to be the best way to show that I have meet the "standard of care" and will help protect me in any future malpractice lawsuits.

[JoshuaAdamsRN]

ADPIE - assessment, diagnosis, plan, intervention, evaluation. We have an initial systems flow sheet for assessment, and then a narrative note. On the narrative note, you address the elements of the nursing process. For example, this is exactly what my documentation on the narrative would look like for a patient having an asthma attack:

1201: Nsg dx - impaired gas exchange. Pt to rm 4 by wheelchair. C/o sudden onset extreme SOB. Able to speak 2-3 words at a time. Room air SpO2 88%. Audible exp wheeze. Placed on cardiac monitor and O2 via NRB at 15 Lpm. MD aware of pt. arrival.

1203: MD in to examine pt. SpO2 increased to 95%. Aerosol treatment ordered.

1204: Albuterol/atrovent via neb. Portable CXR done.

1208: SpO2 maintained at 96-98%

And so on. So it addressed assessment and diagnosis, the plan is obvious, implementation steps, and evaluation (ongoing assessment).

[NurseJacqui]

Whatever happened to Airway Breathing and Circulation?