Qustions about Focus Assessment Charting!

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Hi everyone!

I just have one question. During my externship in the ED I had a really difficult time charting focus assessments. I am so stuck on head to toe. My preceptor kept telling me who cares about bowel sounds when you have a tib fib fx, but I still had a hard time. Is there any books out there that is made for ED charting that I could purchase? Thanks.

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to tell you the truth, i wouldn't want to rely on an "er charting book". it's normal for externs, new grads, orientees to feel that way about charting in the er. i used to go around the er and read the notes of those nurses who were excellent to see how they charted. your experience, certain situations, and different levels of patient care will dictate how you chart. when breaking it down, the patients we see in the er as a whole are the same across the board (i.e. chest pain, sprained ankles, shortness of breath, lacerations, etc.) as far as charting is concerned. you will find your groove and be good at as time progresses and experience is gained.

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I was just going to post about this! I spent the summer as a nurse extern on a tele unit, but plan to go to the ED on graduation (hopefully!). That head-to-toe assessment is burned into my brain. Good suggestion of looking at another nurses charts (with permission) though. Any other tips?

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http://www.fetchbook.info/showImage.do?search=0781718619

Quick Reference To Triage by Valerie G. A. Grossman

although this book refers to triage, it gives you excelent insight to assessment and interventions in nursing lingo that you can incorportate into your charting. quick, concise, and to be used in study for the CEN.

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We had a pt. come into the ED with abd pain. Nurse focused only on that. The patient coded: he'd been having an MI all along. So when I have someone come in, I'll do at least a mini head to toe.

You can already have a good idea of mental status just by talking to the patient. Everyone gets at least upper lungs posterior and anterior auscultated, that sort of thing. If someone comes in and says they broke their ankle in a fall, I check pupils and abdomen. That kind of stuff.

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Thanks for your replies. Charting is just so different in the ED. Carotid I will check out that book. Great suggestions everyone.

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