Use this format to document injuries

When an employee is injured, "all your actions, from your initial assessment to the final disposition, should be documented," says Christine Zichello, RN, COHN-S, CSHM, ARM, FAAOHN, a senior risk control specialist for PMA Companies in Mt. Laurel, NJ.

Your documentation is important to ensure clinical care standards are met. It also provides key information for workers' compensation and Occupational Safety and Health Administration (OSHA) records.

"Careful history taking and early observations can be important data for the employee's care, as well as for workers compensation and OSHA determinations," says Donna C. Ferreira, ANP, MS, COHN-S, senior regional manager at Comprehensive Health Services, a Reston, VA-based provider of workforce health and productivity management solutions. "Your initial history with the employee must be
thorough."

Ferreira recommends using a SOAP (Subjective, Objective, Assessment, Plan) format to stay organized. She gives these examples of what to document for each component:

• Subjective:

Ask these questions to elicit subjective data to document the employee's account of the injury/illness.

— What happened?

— When and where specifically did this happen?

— Was anyone else with you at the time? If yes, who?

— Did you seek any treatment for this yet? If yes, where, and when? What was done? Were medications given and if so, what doses? Were any workplace restrictions placed? What follow-up is planned?

"Add subjective statements from supervisors and witness if appropriate," says Ferreira. "Assess any other subjective data about the injury, to include pain level, limitations the employee states he or she has, and sleep
patterns."

• Objective:

"Document facts the examiner can see, smell, touch, hear," says Ferreira. These include:

— How the employee ambulates, gets up and off the exam table;

— Range of motion, in measured degrees, of the affected body part;

— Color, palpable temperature, and swelling noted of affected body part;

— Any odors noted;

— The employee's appearance, eye contact, fidgeting, wringing of hands, and volume of voice.

• Assessment:

"Here, nurses would use a nursing diagnosis such as 'Altered comfort related to left hand injury,'" says Ferreira. "Mid-level professionals and physicians write diagnoses."

• Plan:

Document care and instructions given to the employee. List specific workplace restrictions, any referrals to other health care professionals, and the follow-up plan. "If no follow-up is necessary, it may be wise to document the employee was instructed to return to the occupational health professional with any questions or problems in the future," says Ferreira. She offers this sample work-related injury "SOAP" performed by a nurse practitioner:

Subjective

Patient states at 8 am this morning at the #4 Substation, he stepped in a rut while getting out of the bucket truck. He said his left knee "gave out" and he felt sharp pain on the inner aspect of the left knee. He states his supervisor was present at the time of the injury and drove him to the company Medical Department.

Objective

Ambulates with a moderate limp. Left knee 2+ edema. Tender to palpation on medial aspect of left knee. L. Knee: Flexion is to 110 degrees, extension is to 5 degrees, negative anterior drawer sign, positive for McMurray's test. Left knee warmer to touch than right knee.

Assessment

Internal derangement left knee, employee claims work-related

Plan

1. The left knee was elevated and ice pack applied over layer of cloth x 20 min.

2. Referral to orthopedist

3. Restrictions written including sedentary work, elevate left leg

4. Told employee to ice the left knee 20 min. 3 x/day, elevate and take Advil 400mg PO TID PRN with food. The Knee Owner's Manual was given to him to read.

5. Follow up visit in 1 week