I am currently switching back to ER and dialysis, and for the first time in almost two years, I am back to ER as a part timer. Back then being a newly graduated, and now having experienced quite a lot of things... I am really wanting to know more on doing a proper documentation on a patient's triage report.
The ER that I am working in right now is a mix of outpatient, dressing bay and the usual cuts, accidents and sometimes emergency cases. What I am not happy with is the quality of documentation that we do. I know that with so many patients switching in and out, we tend to do things on a flash. And a result, what we wrote on the triage sheet can be so simple. Many nurses thought that since the doctor will ask basically the same thing again, there's no need to really ask as much. But I beg to differ as a nurse's report is as important when it comes to legal matter. I can say that what we wrote in the report, gave an impression to the reader what we asses back then.
My question to seasoned ER nurses: how do you do it in your place? And are there are online links where I can see an example.
Here's what some of us might wrote.
Situation: Patient came in complaining of a cough.
Example 1
c/o coughing for five days
Example 2
c/o productive cough 5/7, yellowish sputum
lungs clear on auscultation
fever c chills, generalised body ache
taken pcm II/II @ 6.00 pm, benadryl expectorant for 3/5 with no relief
Well, I guess I could think of a better example but I think that would give you an idea. I try writing as simple and as thorough as possible but it seems hard when you are pressed for time and don't know what to write or prioritize. So I am wondering what you guys are writing on your report. Do you draw diagrams or body parts affected? Like in cut wound: do you write the length/extend of the injury, profuse bleeding, and specify exactly where it is (lower part of index finger, 2 cm across, deep cut wound) (2 puncture wound marks - 2.5cm apart from another).
I don't disagree with what you're saying, and I did note that I personally strongly prefer "more is more" to "less is more" when it comes to charting.
I have not worked in an ER where the triage nurse had the time or the privacy to adequately auscultate lung sounds ... but if I did work in such a place I can guarantee that I would listen to lung sounds for respiratory & cardiac chief complaints to the extent that it did not delay getting a patient out of the triage booth and back into a treatment room where they belong.
I'd be very interested to hear more about how your mid-levels triage (in its literal definition -- "sorting"). Thanks in advance.
nor have I - never the privacy, but always did it quickly. Never had the privacy either for a rectal temp on a baby.... but it had to be done.
MassED, BSN, RN
2,636 Posts
nor have I - never the privacy, but always did it quickly. Never had the privacy either for a rectal temp on a baby.... but it had to be done.