From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
A comprehensive accent documentation in emergency medicine should include the following elements: Patient identification, chief complaint, history of present illness, past medical history, medications, allergies, social history, family history, review of systems, physical examination findings, vital signs, diagnostic studies ordered and results, medical decision making, differential diagnosis, treatment plan, disposition, and follow-up instructions. When documenting, use clear chronological order for the history of present illness, noting onset, duration, severity, exacerbating and alleviating factors, and associated symptoms. The physical exam should be thorough but focused on relevant systems. Document all interventions performed, medications administered with dosages and times, patient response to treatments, and any consultations obtained. Include your clinical reasoning process, explaining why certain diagnoses were considered or ruled out. For disposition, clearly state whether the patient was discharged, admitted, transferred, or left against medical advice, along with specific follow-up instructions and return precautions. This structured approach ensures comprehensive documentation that supports medical necessity, facilitates continuity of care, and provides legal protection in case of future litigation, as supported by the most recent study on standardization of emergency department clinical note templates 1. Key elements to prioritize in documentation include:
- Patient identification and chief complaint
- History of present illness, including onset, duration, and severity
- Past medical history, medications, and allergies
- Physical examination findings and vital signs
- Diagnostic studies ordered and results
- Medical decision making and differential diagnosis
- Treatment plan and disposition
- Follow-up instructions and return precautions Using a standardized note template, as shown to be effective in a recent study 1, can help ensure that all necessary elements are included in the documentation. By following this structured approach to documentation, emergency medicine providers can ensure that their documentation is comprehensive, accurate, and supportive of high-quality patient care.