Education Career Articles

Connect Facebook Connect Twitter Connect Google+ Connect Pinterest Connect Stumbleupon

Why Nursing ER Documentation is Critical

Career News September 12, 2013

Introduction

An important part of an Emergency Room Nurse’s Duties is completing ER documentation. Patient data must be recorded accurately to ensure patient health. In some cases where malpractice is alleged, it can legally protect staff. It is also relevant for insurance purposes.

Documentation in the ER

In Trauma Care Documentation, some of the essential ER issues are outlined. Medical records provide chronologic evidence of patient evaluation, treatment, and response to treatment. The record provides a basis for reviewing care quality. The record is also a basis for health team discussions regarding the patient’s status. The treatment plan requires reference to the medical record.

A complete, accurate trauma resuscitation record is an essential both legally and medically. It is essential for staff to understand how to effectively document patient data. The trauma resuscitation documentation can be used to show insurance companies reasons for charging patients additional fees. Insurance companies have been known to disallow charges when documentation is incomplete.

Protecting legal interests of both the hospital and the patient is a tremendously important function of the medical record. The most basic ER documentation must include: patient identification, how the patient arrived, care rendered prior to arrival, relevant history, chronological listing of physical examinations including vital signs, and the results of diagnostics, treatments and tests.

The physician’s orders and diagnostic analysis should be recorded. The patient’s response to the interventions, as well as the intervention itself, must be described. The patient’s condition and state of mind, when discharged from the ER, requires documentation. In the case of trauma patients, mechanisms of injury, Glasgow Coma Score (GCS), spinal immobilization, the status of breathing, circulatory systems and airway also needs to be recorded. Each and every medical record must be accurately documented.

The National Standards of Emergency Nursing Practice require that nurses are responsible for the accurate documentation of patient care. The medical record provides both important information about the patient’s clinical condition and is the basis for lawsuits in alleged medical negligence. Nursing ER documentation is so critical because it is the legal documentation of ongoing patient care and the record of the patient’s reactions to therapeutic interventions.

Critical Aspects of ER Documentation

Critical aspects of emergency department documentation and communication include issues that place health providers at increased risk for liability. While the primary focus of ED should be patient care and safety, other aspects are important as well. The ED record is the only lasting documentation of an ED visit. Its accuracy can have future repercussions. It may be used to resolve legal disputes and insurance claims. There are various types of ED documentation method. Some hospitals use electronic documentation. Patient handoffs from one shift to the next are a critical time for ED.

A Nurse’s Perspective on Patient Documentation

Katie Morales, RN says the most critical times for nurses to do documentation are often when there is the least time for documenting. This might be while the patient has abnormal vital signs, codes and transfers. Another bad time is during shift change hand offs. When taking verbal orders, it’s important to verify medication and record all physician orders.

Within 15 minutes of lab verification, critical values must be reported to the nurse. Within 30 minutes, the nurse needs to let the physician know about the patient’s critical values. When it is not possible to get hold of the physician, the facility’s standard procedure must be followed.

Regardless of the method used for patient documentation, all information must be legible, objective, and free of grammatical and spelling errors and erasures. Allergies should be highlighted. Charting should never be done in advance.

Accurate documentation makes it easier to find changes in the patient’s condition. Documentation should include listing all staff notified as well as actions taken. Part of an RN’s duty is to analyze data and excellent documentation makes that an easier and more reliable process.

Searching Searching ...

Matching School Ads
5 Program(s) Found
Fortis Institute , Grand Prairie
  • Gain Knowledge and Skills While You Earn Your Nursing Degree at Fortis!
  • Accredited
  • Financial Aid
5 Program(s) Found
  • Do you aspire to fulfill an evolving healthcare role as a highly-qualified nursing professional? GCU is the place for you.
  • RNs, pursue your BSN or MSN conveniently online, backed by the legacy of GCU's traditional campus.
  • GCU's bachelor's and master's programs prepare students to fill roles in direct care, management, health education and administrative disciplines.
  • The baccalaureate degree in nursing and master's degree in nursing at GCU are accredited by the Commission on Collegiate Nursing Education
  • Develop with hands-on practice, online and lab simulations and in depth peer discussions exploring best practices.
Good for Working Adults
  • Accredited
  • Online Courses
  • Flexible Scheduling
  • Accelerated Programs
  • Financial Aid
  • Transferable Credits
5 Program(s) Found
  • Online bachelor's programs include BBA, Criminal Justice, IT, Healthcare Management, Pscyhology & Public Health
  • Over 115 years of delivering quality education and personalized attention to students
Good for Working Adults
  • Online Courses
  • Flexible Scheduling
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Earn your degree online from Ashford University!
  • Choose from Undergraduate and Graduate classes
  • Business, Health Care, Psychology and Liberal Arts programs to choose from
  • Apply Now! Classes begin every Tuesday!
  • Online Courses
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Recognized as a Top 20 Best Online Bachelor’s Program by U.S. News & World Report in 2016.
  • Online, campus-based, and evening courses offered in 95 areas of study, including Business, Nursing, Psychology, & more.
  • Endorsed by G.I. Jobs and Military Advanced Education magazine as a Military Friendly School in 2015.
  • Features small class sizes, with a student-to-faculty ratio of 23 to 1.
  • 88% of Regent University students receive financial aid, with $18 million awarded in institutional scholarships & aid each year.
  • Online Courses
1 Program(s) Found
  • Designated as a 2015 Military Friendly® School by Victory Media, publishers of G.I. Jobs®.
  • Each program is designed to instill the knowledge, ethical values, and interpersonal skills of professional practice and to foster values of social responsibility.
  • Offers several flexible learning options, including a blended format that combines campus and online learning.
  • Several scholarship opportunities are available for students who qualify.
Good for Working Adults
  • Online Courses
  • Flexible Scheduling
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Ranked among the Best National Universities in 2015 by U.S. News and World Report.
  • Ranked 8th among the Best Online Graduate Education Programs in 2015 by U.S. News and World Report.
  • A private, co-ed college founded in 1821 and located in downtown Washington, D.C.
  • Its student-faculty ratio is 13:1, and 55.1% of classes have fewer than 20 students.
  • Has distinguished alumni including Senator Harry Reid, former U.S. Secretary of State Colin Powell, and actress Courtney Cox.
Show more [+]
  • Accredited
  • Online Courses
  • Accelerated Programs
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Designated a 2015 Military Friendly School by Victory Media for the 4th consecutive year.
  • Listed on the President’s Higher Education Community Service Honor Roll in 2013, for the sixth consecutive year
  • Links students to hundreds of training opportunities (beyond their traditional internships and practicum) at their many “partner agencies” in each of their local communities.
  • Accredited by the WASC Senior College and University Commission (WUSCUC).
  • Online Courses
  • Financial Aid
  • Education Connection is a 100% Free College Matching Service used by 50,000 People Daily.
  • Get Matched to the Right Business Administration and Management, Accounting, Healthcare Administration, Marketing and Entrepreneurship Degree Program for YOU.
  • Affordable and Flexible Business Degree Programs from Top Colleges Across the Nation. Both Online And Campus!
  • Just Fill Out a Few Questions and You Can Find Your Perfect Business Degree Program Within Minutes.
  • Start Using our Fast, Free, and Easy Matching Service Right HERE and Right NOW!
  • Online Courses

Searching Searching ...

Matching School Ads
5 Program(s) Found
  • Which career path will you take – Business, Nursing, Education, Psychology? Something else? GCU offers more than 100 majors to get you started!
  • Colangelo College of Business: Features more than 25 programs from the bachelor through the master's level, including several high-demand MBA programs and an accelerated accounting degree.
  • College of Nursing and Health Care Professions: Rich 25-year history providing outstanding health care and nursing degree programs, including an RN to BSN program & master's in nursing degrees.
  • College of Education: Whether you are looking to start or advance your career as a teacher or administrator, GCU offers bachelor’s and master’s in education degrees in key areas.
  • College of Humanities and Social Sciences: Provides a job focused education and features a variety of programs from counseling and psychology to justice studies, history and English literature.
  • Does something else interest you? GCU also offers programs in Doctoral Studies; Theology; Science, Engineering & Technology; and Fine Arts & Production. Speak with an enrollment counselor today!
Good for Working Adults
  • Accredited
  • Online Courses
  • Flexible Scheduling
  • Accelerated Programs
  • Financial Aid
  • Transferable Credits
5 Program(s) Found
  • Online Bachelor's programs include BBA, Criminal Justice, Psychology, IT, Healthcare Management & Public Health
  • Over 115 years of delivering quality education and personalized attention to students
  • Provide a range of campus experiences and services online including advising, tutoring, student community, and career services
  • Give students and alumni access to career assistants who help with resumes, cover letters, job hunting, and more.
Good for Working Adults
  • Online Courses
  • Flexible Scheduling
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Earn your Master of Public Health Online from GW in 12 months.
  • GRE waivers available for qualified applicants.
  • Advance your career in a range of industries, including epidemiology, public health and biostatistics.
  • Accredited
  • Online Courses
  • Accelerated Programs
  • Financial Aid
  • Transferable Credits
1 Program(s) Found
  • Recognized as a Top 20 Best Online Bachelor’s Program by U.S. News & World Report in 2016.
  • Online, campus-based, and evening courses offered in 95 areas of study, including Business, Nursing, Psychology, & more.
  • Endorsed by G.I. Jobs and Military Advanced Education magazine as a Military Friendly School in 2015.
  • Features small class sizes, with a student-to-faculty ratio of 23 to 1.
  • 88% of Regent University students receive financial aid, with $18 million awarded in institutional scholarships & aid each year.
  • Online Courses
1 Program(s) Found
  • Earn your degree online from Ashford University!
  • Choose from Undergraduate and Graduate classes
  • Business, Health Care, Psychology and Liberal Arts programs to choose from
  • Apply Now! Classes begin every Tuesday!
  • Online Courses
  • Financial Aid
  • Transferable Credits

Login to your account

Can't remember your Password ?

Register for this site!