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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.

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