Documentation in the healthcare setting should be clear, concise, objective, timely, and accurate. The medical record documents a patient’s trajectory through the healthcare system. It is used as a communication tool among all participants in the patient’s care team to coordinate patient care, and much of the record is now shared directly with the patient through online portals. The patient’s medical record is also a legal document and will be a very important part of any medicolegal proceedings. It is important that the emergency department (ED) technician develops good documentation skills.

Use of Documentation

The ED technician (EDT) is part of a provider team caring for the patient, all of whom contribute to the patient’s record. In most EDs, the EDT is responsible for documenting all procedures they perform, including patient transport, so the range of documentation will parallel their scope of practice. Examples of EDT documentation are intravenous catheter insertion, patient transport, collection of patient belongings, point-of-care testing, electrocardiograms (ECGs), vital signs, and splint application ( Table 25.1 ).

Table 25.1

Example of ED Technician Documentation Notes

Vital signs Postmortem care
Patient safety checks Blood draw
Patient ambulation Swab/culture specimen
Suspected abuse Suctioning
Maintenance of seizure precautions Placing patient on oxygen
Immobilization/restraints Assisting physician in orthopedic reduction
Cardiopulmonary resuscitation Assisting physician with cast
Electrocardiogram Splint application
Orthostatic vital signs Orthopedic devices application
Intravenous access Providing crutch training
Wound care Waste disposal
Type of device, location of device, distal pulse, Patient transport Facilitating environmental services

Table 25.2 describes the specific elements of common note types. Some documented information, such as vital signs and point-of-care test results, can communicate aspects of the patient’s current health status that determine the patient’s plan of care. All members of the healthcare team are responsible for clear, concise, and timely documentation.

Table 25.2

Specific Elements of Different Types of Notes

Procedure Essential Documentation Components
Intravenous access Catheter size, insertion site, number of attempts, skin prep used, patency, dressing type, special equipment used (such as ultrasound)
Wound care Wound site, site condition, dressing type
Orthopedic devices Type of device, location of device, distal pulse, motor and sensation pre- and postdevice application, instructions given
Patient ambulation Steadiness of gait, amount of assistance needed, safety precautions in place
Electrocardiogram Time and date of completion, time and date shown to provider, name of provider shown
Patient transport Method of transport (e.g., wheelchair, stretcher, ambulatory), destination, specialty equipment or monitoring devices used in transport

Electronic Medical Record

In 2014, Federal legislation required that all hospitals implement an electronic medical record (EMR) system in order to participate in Medicare and Medicaid. Although there are a variety of hospital EMRs, the three largest are Epic (29% of US market), Cerner (26%), and Meditech (17%). EMRs can have hospital-specific modifications, resulting in slight variations of the charting system among different hospitals using the same platform. The EDT should follow guidelines for documentation based on their hospital’s policies and procedures.

In the ED, the tracking board is the central display in all EMRs. The tracking board attempts to present large amounts of data in a concise way and allows healthcare providers to pinpoint the patient’s physical location within the ED and the status of their evaluation. Standard information displayed on the tracking board includes the patient’s age, gender, vital signs, Emergency Severity Index triage level, patient-specific attributes (such as allergies), and the status of certain tasks. There may also be a staff comments section used for short notes for intradepartmental communication that often does not become part of the permanent medical record. Tasks to be completed and patient-specific attributes are often represented by tracking board icons. See Fig. 25.1 for an example of a tracking board.

Jul 15, 2023 | Posted by in EMERGENCY MEDICINE | Comments Off on Documentation

Full access? Get Clinical Tree

Get Clinical Tree app for offline access