Hello all! Today’s post will be a quick read. If you work in the ER like me, you will know there are a lot of moving parts. ER nurses are notorious for minimal charting on patients. So keep reading for three easy tricks!
Disclaimer: This post is for educational purposes only. All thoughts and opinions are my own.
1. CHART AT THE BEDSIDE.
This is something, I was taught during clinicals in nursing school and it has saved me so much. I adapted it once I got to the ER. For example, if I get a new patient once I go in and hook the patient up, complete their triage and listen to them (ER nurses use your stethoscopes), I will make sure to throw in my set of assessments based on their complaints. My hospital system uses EPIC, which I love. I can chart in a few clicks! If something changes with the patient status and I am about to hand a medication, I will throw in an updated assessment based on the status change.
2. CHART YOUR INTERVENTIONS/INTERACTIONS W. PROVIDER.
I have noticed a lot of nurses don’t do this. Make sure to document what you do for the patient. Not only is this important for billing purposes, but also for when your patient goes upstairs (if they are being admitted). The nurse upstairs has no idea what you did if they don’t see anything charted. Here are some interventions I’ve seen people forget to chart in the ED: linen changes, positioning assistance, bathroom/ambulation assistance (make sure to chart how well they ambulated), enemas, cardiac monitoring, rate/dose changes IVs (yes, people forget to chart these all the times), etc. I also make sure to chart whenever I speak with my providers regarding the patient. I also like to chart when the provider is at the bedside if I am there or I see them step into the room.
Extra Charting Tip, ED Edition: If you do a brief change and full linen change, you have done a skin assessment. Please chart it and let the nurse upstairs know in report.
3. DOWNTIME? CHECK YOUR CHARTING.
Sometimes in the ER you may have a little bit of a “lull”. This rarely happens for me, but if you do, review your charting. Remember that your charting is telling a story. Make sure you told a story.
Those are my quick tips for keeping up with charting in the ED. Consistency is key with charting. Remember you have a license to protect. Thanks for reading!