Title:Guideline for Completion of the ED Nursing Record and Continuation Sheet (MR 850, 2A)

Instructions:

General Information: 

The Emergency Department Nursing Record is formatted in sections to allow efficient documentation of the assessment and care of all patients from the lowest level 5 to most acute level 1. The bolded section of this form is to be completed for all Emergency Department patients.   For level 4&5 patients, presenting with non-emergent complaints, only the bolded section of the assessment is required.    For the more acute triage levels, 1 - 3,  a focused assessment of systems pertinent to the chief complaint will also be completed and documented.  

The “Nursing Diagnosis” listing represents the most commonly seen conditions in the Emergency Department.  ENA, Emergency Nursing Core Curriculum has been adopted as departmental standards for nursing plan of care and reside in the department for review as needed.  A documented focus note update, including vital signs is required for each ED patient every four hours or more frequently if indicated by patient’s condition.

General Information:

(*) indicates a mandatory field which is to be completed on every Emergency Department patient.

Form Abbreviations:

LWBS = left without being seen

NCPS = Non Communicative Pain Scale

LOP = level of pain

NC = nasal cannula

NRB = non-rebreather

SSU=Short Stay Unit

AMA= Against Medical Advice

R = right

L=left

N/A = not applicable

Y=yes

N=no

SMC = sensory, motor, circulation

RA=right arm

LA=left arm

RL= right leg

LL = left leg

Alt = alteration

WDWN = well developed, well nourished

Ineff = ineffective

NIBP=non-invasive blood pressure

Emergency Department Nursing Record:  (front)

1. Place either the patient sticker during down time or confirm accuracy of computer print out name in the top left hand corner of the form.*

2. Document the Room Number into which the patient is placed in the Emergency Department.*

3. Document the time the patient was placed in the room.*

4. Check the “see computerized triage sheet” box to draw attention to computerized triage document.*

5. Document the patient’s primary language with a check for English or Spanish.  For other languages, check other and write in the appropriate language on the adjacent line.*

6. In cases when there is not an emergency department room immediately available following triage, check the “Pt Triaged – back to waiting room” and enter the “time” on the line so marked. 

7. Enter the date and time that all mandatory fields (indicated by an * in this guideline) are completed in the “Initial Nursing Assessment Date/Time” field.  Mandatory Fields for triage level 1 - 5 include sections bolded on the form.  For triage level 1 - 3 ,check and/or write in all appropriate findings for sections*:

a.       Mental Status*

b.      Behavior – all patients exhibiting hopeless/depressed behaviors should have a suicide assessment.  Indicate with a check, when initiating PEEP protocol.*

c.       Pain – The use of the Numeric vs NCPS  pain scale is usually determined at triage. If the numeric scale is used initial pain assessment should include severity 1-10, location, onset, characteristics, duration/frequency, alleviating factors, aggravating factors of pain.*  The NCPS is recorded on the back of the nurses notes using the key in the Nurses Note bedside chart.* If the NCPS is indicated at the time of triage but the patient is communicating during the initial assessment the behavior change needs to be reflected in the focus note.

d.      Chronic Deficits*

e.       Living Situation*

f.        Domestic violence screen – Indicate patient response by circling “Y” for yes and “N” for no.*

g.       Nutrition:   Record stated Height /Weight , WDWN=Well developed well nourished)*

h.       Speech *

i.         Skin/mucous membranes*

j.        Safety – Check factors which apply to patient  Considered the following factors when determining whether the patient is at risk for falls: greater than 65 years of age,  positive history of falls in last 3 months, answers yes to the question “ requires ambulatory devices (cane, walker, braces, crutches, wheelchair), confusion or disorientation, inability to follow instructions, physical conditions of vertigo, unsteady gait, seizure disorder, certain medications ( ie narcotics, sedatives, psychotropics, anti-hypertensives). Patients who are identified as being potential fall risks need the High Risk procedure implemented *   

k.      Barriers to learning:  Indicate by a check whether the learner is the patient, a caregiver, or other – if other write in the relationship to the patient.  Indicate by a check the preferred learning style as defined by the learner.  Check the level of motivation based upon your observation and interview of the patient/ learner.  Write in the appropriate “barrier code”.  If  “O” for other selected, write in the barrier.* 

8. Sign your first initial, last name and title in the RN box indicating that you completed the mandatory bolded section for your patient. *

9. For patients triaged to level 1 - 3, complete a focused assessment of appropriate systems based on chief complaint of the patient.  For those systems not pertinent to the patient’s complaint, indicate “ N/A”.  Write additional assessment information as necessary in the narrative section of the front page.  Each narrative entry should be timed and signed with first initial, last name and title of the staff member making the entry.   

10. For triage level 1 - 3 patients, in the event that assessment can not be completed, indicate this by checking the appropriate box adjacent to the “not assessed” line.  If “other” is checked – write in the reason. 

11. Sign your first initial, last name and title in the RN box indicating that you completed the focused assessment on level 1 - 3 patient.

12. Based upon your nursing assessment,  check the Nursing Diagnosis/ Collaborative Problem that reflects your patient’s condition, or check “other” and write in the nursing diagnosis/ collaborative problem of your Ö* Review the plan of care for this nursing diagnosis/ collaborative problem in the ENA Emergency Nursing Core Curriculum.  Note: Due to the collaborative nature of ED care,  ENA plans of care contain independent, interdependent and dependent interventions.  An MD order will be required for interventions that are beyond the scope of independent nursing practice.  If individualization of the plan of care is required based on your patient’s unique condition– document this requirement in the narrative section.  Time and sign with first initial, last name and title all narrative notes.  Implement the plan of care and document  interventions and attainment of outcomes of the plan as appropriate.. 

13. Use the narrative section for timed narrative/focus notes related to outcomes of plan of care, for continuation of initial assessment,  continued assessment, status focus note update at least every four hours or as indicated by patient condition date and time each entry.

Emergency Department Nursing Record ( back)

14. Procedures/ Interventions: Each entry is to be timed and initialed.    Check the box next to interventions/ procedures appropriate to your patient.  When oxygen is utilized, check the appropriate box to indicate the method of delivery and write in the number of liters.  For patient precautions, write in the type being implemented ( ie seizure, neutropenic, falls, contact isolation).  When cardiac monitor is initiated, time, initial and check the “cardiac monitor” box, then write in the rhythmn interpretation next to the box.  Future cardiac rhythmn interpretations should be completed every 12 hours, or when a change in patient rhythmn is noted. Time and initial when ice/elevation performed or when initial venipuncture is performed. Record the time and initial of RN or PCT that assists MD with pelvic exam. Time and initials should be recorded if restraints are required and the restraint flowsheet is initiated  

15. IV Therapy: Record the IV site of each IV access and the size of the IV catheter under the appropriate column.  When multiple IV accesses are needed at one time,  number the access site, record the number adjacent to the IV site in the document. 

16. IV Intake: Record the time fluid was hung in the time column. Record the solution hung, and the bag number. All IV fluid bags are to be numbered to assist in maintaining accurate input. If the patient arrives from the field with an IV in place, record PTA ( prior to arrival) in the time column, enter the solution in the appropriate column and record LTC ( left to count) with the amount remaining in the bag in the amt. column.    

17. Upon the completion of each bag of fluid, enter amount taken under the “Amount of fluid absorbed” column

18. Total Fluids:  Record and.Total amount of IV fluids  (e.g. Blood, Saline) absorbed during ED stay.  If the patient is converted to ADH hold,  carry over and record amount of hanging fluid as LTC (left to count) on inpatient record

19. Record PO fluid  amount – total amounts during ED stay. 

20. Total Output:  Record the time the output is obtained beneath the time column.  For urine,  record the amount obtained beneath the urine column.  For other types of output (e.g. NG, Chest Tube), write in the type at the top of the blank output column and enter the amount beneath the column, adjacent to appropriate time.  Total output at the completion of ED stay.  

21. Document vital signs, cardiac rhythmn, pulse oximetry measure and pain score in the appropriate columns.  Each entry should be timed 

22. Procedures:  Indicate the procedures performed on patient and document pertinent requested information.  All entries should be initialed and additional related comments can be added to “comments” line.  Note:  All invasive procedures require a “time-out” to be conducted and documented on the MD procedure note.  

23. Non Communicative Pain Assessment: Using the Non-communicative pain scale key posted in the nursing chart back record why the patient is unable to report, reason for assuming pain, behaviors, interventions, reassessment.

24. If the decision to admit an ED patient has been made and the transfer to the inpatient unit can not be accomplished within 2 hours,  convert the patient to ED hold.  Check the appropriate level of care and record the time M/S or ICU hold initiated (mandatory on all hold patients).  Close out your ED record and begin documentation on inpatient record 

25. Disposition:   Check the appropriate disposition – write in information as indicated for admit patients, report.  Check all appropriate boxes.       

26. Personal Belongings: At the completion of the ED stay, document all personal belongings in the possession of the patient.  Indicate disposition of these belongings as appropriate.  For PEEP patients – see PEEP policy for personal belongings 

27. Each ED care provider documenting on this form should place Initials, signature,  title and print name in the appropriate boxes. 

28. Record discharge vital signs within 30 mins of patient D/C *

29. Write in date and time and and check disposition condition when patient leaves department.  Patient may be  discharged from the ED, admitted to the hospital or transferred to another facility.    

30. When an RN discharges a patient from the department,  the RN should record their signature.   For low acuity patients, the MD may discharge without nursing involvement and this should be indicated  by checking “MD d/c” box.

31. Nurses Notes Continuation Sheet (front and back).

32. Patient sticker front and back of form.*

33. As number 13 

34. As number 21

35. As number 15

36. As number 16
37. As number 17
38. As number 18
39. As number 19
40. As number 20
41. As number 23
42. As number 27

Example: Emergency Department Nursing Record

RESOURCE PERSON(S):  Corinne McKay, RN