Documentation

In today's episode we are going to talk about documentation in the ED. It is very important that we are complete but concise in our documentation in order to provide an accurate record for the patient's ED patient to protect them and ourselves from problems down the road. Good documentation is good patient care so we need to know how to do this efficiently. We will review each part of the chart starting with the triage note and ending how to give good discharge instructions. We'll also review some tips and tricks of the trade regarding abbreviations that will make your charting faster, how to document interactions with our consultants, and even what to do when you have to document a difficult situation with a consultant.