Use this checklist when you document

You should include the following items in your medical record 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 suspected child, elder, or spousal 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.