Use this checklist when you document

You should include the following elements in your documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/ quality management at Lynx Medical Systems in Bellevue, WA:

  • Timed and initialed entries
  • Means of arrival
  • A triage note or presenting problem and pertinent history of the illness or injury
  • Allergies and current medications
  • Important factors that put the patient at high risk per hospital policy (such as potential abuse)
  • Weight, visual acuity, or other factors (if appropriate for age and presenting problem)
  • Initial vital signs and a reassessment if abnormal or changed during the emergency department course of treatment
  • All interventions and patient responses
  • Some type of pain assessment scale
  • Orders noted and initialed per hospital policy
  • An assessment of the patient’s psychosocial needs and ability to understand teaching and instructions
  • Discharge status
  • Disposition and time
  • Referrals and communications with other caregivers or providers regarding the patient
  • A patient’s leaving against medical advice
  • Nurses’ signatures