Pre-Saved Quick Notes

Why do you need a standard note for discharge? Are you doing discharge documentation in the computer?

I will only add a note if there was an issue that may be preventing them from discharge, such as an elevated BP or they were drunk and very unsteady and now have a more normal gait.

A lot of my coworkers use quick notes. I don't. I'm a fast keyboarder and it only takes me a moment to type up a note if I feel the need to do so.

Why do you need a standard note for discharge? Are you doing discharge documentation in the computer?

Yeah, for a standard DC, I don't see a need for a note, but there are a lot of situations where the click boxes don't paint the full picture.

For a couple of repeat customers who "lose" something every single time they avail themselves of our services, I always note that they left with all of their belongings, particularly after I had to talk with Risk Management about something they claimed to have lost in the room while under my care (they didn't- I never saw/touched/held/had any contact or knowledge of said item at any time during or after their stay).

For the person who declines repeat VS at DC (steady gait, no acute distress, pink/warm/dry, etc).

For the unsatisfied customer (left department yelling that staff are "a bunch of ########", observed spitting on the door on the way out, etc).

If uneventful, I just use the click boxes and don't write a note.