Essential Components of Nurse Charting in the Emergency Room Setting
Effective nurse charting in the emergency room must include comprehensive documentation of vital signs, patient assessment findings, interventions, and time-sensitive information to ensure patient safety and continuity of care.
Core Documentation Requirements
Patient Identification and Triage Information
- Complete patient identification including name, date of birth, medical record number, and arrival time 1
- Emergency Severity Index (ESI) triage level assignment with supporting rationale 1, 2
- Chief complaint and time of symptom onset, particularly the "last known well time" for time-sensitive conditions like stroke 1
- Mode of arrival (ambulance, walk-in) and whether family/caregivers are present 1
Vital Signs Assessment
- Complete set of vital signs documented at least every 8 hours, with more frequent monitoring for unstable patients 3
- Traditional vital signs: temperature, pulse, blood pressure, respiratory rate, and oxygen saturation 4
- Extended vital signs when appropriate: pain assessment, level of consciousness, and urine output 4
- Documentation of any abnormal findings requiring intervention 1, 3
Clinical Assessment Findings
- Systematic assessment using a comprehensive harm prevention framework (skin integrity, continence, abnormal clinical findings, nutrition, cognitive state, medications, mobility, pain) 1
- Documentation of neurological assessment findings using standardized scales when appropriate (e.g., Glasgow Coma Scale, NIH Stroke Scale) 1
- Objective data describing patient conditions rather than subjective interpretations 5
Interventions and Treatments
- All medications administered, including oxygen therapy with specific flow rates, delivery methods, and patient response 1
- Documentation of oxygen saturation monitoring for at least 5 minutes after starting or changing oxygen therapy 1
- Nursing interventions performed in response to abnormal findings or deterioration 3
- Time of notification to physicians and other healthcare providers 1
Time-Sensitive Documentation
- For stroke patients: door-to-doctor time (target: 10 min), door-to-CT completion (target: 25 min), door-to-CT interpretation (target: 45 min), and door-to-thrombolytic therapy (target: 60 min) 1
- Documentation of rapid response system triggers and actions taken 3
- Time-stamped entries for all significant events and interventions 1
Special Considerations
Communication Documentation
- Use of standardized communication tools like SBAR (Situation, Background, Assessment, Recommendation) during handoffs 1
- Documentation of any language barriers and interpreter services used 1
- Record of communications with family members and the patient's medical home 1
Electronic Documentation Best Practices
- Use of standardized templates and care plans to ensure comprehensive documentation 5
- Documentation of access to previous medical records, imaging, and laboratory results that influenced clinical decision-making 6
- Use of configural vital signs displays when available to improve speed and accuracy of data interpretation 7
Safety and Quality Measures
- Documentation of patient safety measures implemented 1
- Recording of any patient identifiers and allergies 1
- Documentation of patient and family education provided 1
Common Pitfalls to Avoid
- Failing to document the "last known well time" for stroke patients, which is critical for treatment decisions 1
- Incomplete vital sign documentation, which can lead to missed deterioration 3
- Checking off interventions without documenting their actual execution 5
- Inadequate documentation of patient response to interventions 1
- Failing to document communication with physicians and other healthcare providers 1
Remember that thorough documentation in the emergency setting not only supports patient care but also serves legal and quality improvement purposes. Documentation should be timely, accurate, and reflect the nursing process throughout the patient's emergency department stay 1.