Prioritization in the ER

I'm not sure if you are asking how to prioritize what to put into your documentation or how to skip documentation until later. There are times that my assignment is switched at a moment's notice depending on what is needed for the department. I need to be able to leave my charting quickly and don't have time to go back and chart.

I always try to document in real time in the ED whenever possible. If it is paper charting, I take the chart with me into the room and document as I go. If it is electronic, I open the computer in the room, link to the monitors and document as I go. If I get into a critical situation and I didn't start documenting when things first started getting critical I start where I am. I document what is happening in real time right then so I only have to back track on a very few things at the beginning and most of my charting is done.

The key to prioritizing what to put into your charting is to visualize what you want your outcomes to be and document the nursing process you used to develop your plan. It sounds complex but you can get really sharp and fast at it. Ask yourself, "What do I think is going on? What do I need to show that I have considered and ruled in or out? Have I assessed the system/s involved enough to get a good picture? Does my treatment follow my assessment and plan? Have I documented the outcomes to my interventions as I go? Did I do a final summary to show where my patient is after what I have done? Did I meet the QM criteria?"

It is an art to be able to document well and care for your patient at the same time. You will get it!

Thanks! Really helpful points. My issue is how to skip documentation til later.

Don't skip documentation until later, instead learn how to be concise and short.

So Don't say this:

"patient asked to ambulate to the bathroom, ambulated with supervision of a nurse times one with strong steady even gait. Pt voided 600ml clear amber urine without problems. pt currently sitting at edge of bed in no distress with parents at bedside, call bell in reach, dinner tray at the bedside."

Say "Patient ambulated to the bathroom with supervision. Voiding without problems. Pt in NAD, parent at bedside."

Thanks! Really helpful points. My issue is how to skip documentation til later.

The ER is NOT the place to skip documentation until later, because, with any luck, the patient will not be there later. Chart as you go.

Agree with altra, chart on the fly. If you hold til later, you'll stay very late and have shoddy charting. I've some chart reviewing over the years and have seen this with those who don't chart as they go.

So what happens if you keep getting patients or you get a really sick one?

We have computers in the room or I use my brain sheet....

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Love it!

OK so let's say I'm in middle of writing my note or putting in my assessment of my critical patient and then the charge calls to say she's bringing a 3 back. Do I finish documenting for 2 minutes or go and see patient? (assuming that tech is busy)

A level 3 pt can, by definition, wait to be seen by the nurse.

In fact, is there any particular reason you need to see the pt before the doc?

A couple thoughts-

Some folks who have trouble keeping up documenting are actually doing too much. In other words, if you are charting the bowel sounds on your sprained ankle, the problem isn't the time it takes to chart. The problem is you listened to the belly of a sprained ankle. A particular challenge for floor nurses who switch to ER is staying focused on the complaint.

Also, you may have some control over your work flow. I generally focus on getting pt's out the door, and rooms cleared for the next. But, if I have a charge nurse who rewards my efficiency by slamming me, I alter my pace. IE- I could dispo and clear room 1 in 2 minutes. Instead, I do a five minute task in rm 2, and catch up on my documentation. Then I dispo room 1.

I agree, chart on the fly. Keep it concise. Finish charting on your critical patient before going to see your Level 3.

Chart as you go. As a previous poster said you need to be thinking about the assessment of the chief complaint. If my patient comes in complaining of SOB I'm going to do a thorough lung and cardiac assessment. Other than that I'm not worried about what their bowel sounds are. Short. Sweet. To the point. Targeted.

I'm not telling you it's going to be easy, I'm telling you it's going to be worth it.

Author: Art Williams