Documentation

05/01/14 • -1 min

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.

Previous Episode

Asymptomatic Hypertension

The patient's blood pressure is 190/80 but they feel fine...how do we treat these patients in the ED? Labs? EKG? BP meds? Admission???...but they are here for an ankle sprain! Asymptomatic hypertension is a challenging complaint to deal with in the ED because of so many conflicting opinions and worries but it doesn't have to be difficult. In this episode, we'll discuss a systematic and rational way to evaluate patients with asymptomatic HTN, do limited and targeting testing, and get them the right followup while calming the patient's fears and avoiding harm.

Next Episode

Acetaminophen overdose

Today's episode talks about the diagnosis and management of Acetaminophen overdose. This is another addition to the EM Basic Project written by Andrea Sarchi.

We encounter acetaminophen overdose frequently in the ED and we need to be on the look out for this because patients can be completely asymptomatic. If we don't catch it, acetaminophen overdose can result in liver failure requiring transplant or even death unless we interevene early. This episode will review how to properly workup a patient with a known or suspected acetaminophen overdose, what tests to order, and how to decide who needs antidote therapy.