nursingdocbrochure_b4a36f44a8f1f.pdf

7/24/2019 nursingdocbrochure_b4a36f44a8f1f.pdf

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Complete Nursing DocumentationFrom Triage through Disposition

Highly CustomizableEasily adapted to meet

your EDs specification

JCAHO CompliantCaptures all mandated screens,including Disposition

Risk Management & APC CaptureImbedded clinical prompters identifyand assist recording proceduresaccurately and completely

Eliminates Chart Storage ProblemsFast, on-demand chart printingincreases staff efficiency

For More Information Conta

888-417-5588www.ePowerDoc.com

Innovative, New Template Format Produces Fast,

Comprehensive Charting, Easily and Efficiently

The Cost Effective, JCAHO Compliant Solution for Your Nursing Records

NursingDoc


2/14


3/14

NursingDoc

Prompts the nurse to rapidly document all data needed for a comprehensive medical record,

while at the same time meet JCAHO and CMS documentation requirements.

Page 1: INITIALAssessments and Interventions

Nursing

Diagnosis

Nursing

Plan

ExpectedOutcome

Nursing

Assessment

Succinct butappropriate

nursing history

and physical

examination

Triage

Pertinentinformation to

determine triage

level

Chief

Complaint

More than 120unique adult

and pediatric

complaints

Mode of arrival: Walk in Wheelchair Friends Attendant Ambulance Helicopter PoliceSource: Patient Family Friend Guardian Nursing home Paramedic Police InterpreterTiming: Onset ____________ Minutes Hours Days Weeks Months ago

Came on: Suddenly Gradually Pain: Still present Worsened Improved ResolvedLocation

:R L

Generalized Frontal Occipital Parietal Temporal RetroorbitalSeverity: Mild Moderate Severe Like previous headaches Worst headache of lifeContext: History of: Glaucoma Immunosuppression Bleeding diathesis None

Known headache disorder (dx): __________________________________None Other history:

_______________________________________Signature

NURSING ASSESSMENT: Room: ________

Nursing history: Triage assessment reviewed Source: Patient Family Friend Guardian Nursing home Paramedic Police InterpreterPrehospital: CPR Intubat ion O2 IV C-collar Backboard Splints Meds _____________NoneContext: Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposureAssociated signs and symptoms: None

Fever N V Weakness Numbness Photophobia Blurred vision

Other history:

Nasal congestion Lacrimation Aura: Visual Sensory Motor Mood

Nursing exam:

Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsiveRespiratory: R L Bil Wheezes Rales Rhonchi normalCV: Tachycardia Bradycardia Irregular normalNeurologic: Oriented to: Time Person Place Not oriented Unable to test normal

Motor function: R L Arm Leg Face Weak Unable to test normalOther exam:

: am pm

NURSING DIAGNOSIS: Altered comfort: Pain Potential infection

NURSING PLAN: To appropriate area

EXPECTED OUTCOME: Pain control/Absent

_______________________________________Signature

: am pm

CC:HEADACHE

TRIAGE:

Emergency Department Nursing Record

PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia Hi gh lipids Neuro: CVA DementiaHeart: MI Angina CHF CAD Lungs: COPD Asthma GI: PUD GERD LiverGU: UTIs Stones MS: Arthritis Psych: Depression Anxiety Schizophrenia None

Recent hospitalization for: _____________________________________________ Other: _______________________________________________________________________

Medications: None see attached list ______________________________________________________________________________________________________________________________________________________________________________________

Allergies: None Latex ___________________________________________________

Past

Medical

History,

Medicatio

andAllergiare easily

recorded

Optionalother assessme

Completel

customizab

Design youown or pic

from ourmultiple opti

Consistent areto record

Triage vita

signs(including pain sc

and

Triage Acu

Triage vital signs

T P RR BP

O2 Sat P ain Wt lb kg

Triage acuity

Emergent Urgent Nonurgent

Standing

orders

or other init

nursing

interventionare easily

documente

Orders, Interventions, and Results

Standing orders or i nterventions initiatedprior to physician evaluation:

Pvt MD notified: YES NO

Accucheck: __________________

O2: _________________________

IV: ________________________

Monitor ___________________

EKG ______________

XR: _______________________

Labs: _________________________

U preg: + - Control: + -

Breathing treatments ________

Splint(s) ___________________

Dressing (s) __________________

:

:

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:

Other Assessments

Domestic violence screening

Are you in a relationship in which you havebeen physically hurt or threatened by yourpartner? Y N Unwilling to answer

Do you feel safe in your current environment?

Y N Unwilling to answer

Alcohol screening

Do you drink alcohol? Y N

During the last year have you had a feeling ofguilt or remorse after drinking? Y N

During the last year has someone told youabout things you said or did while you weredrinking that you could not remember?

Y NDuring the last year have you failed to dowhat was normally expected of you becauseof drinking? Y N

Do you sometimes take a drink in the morning

when you first get up? Y N

1999-2001 ePowerDoc, Inc. v. 3.0 Circled = positive Not circled or / = negative Lined out or section completely blank = not assessed

You r Ho s A dd re sspital

And your charts are customizable to meet your own individual needs!

19992004 ePowerDoc, Inc.


4/14

Page 2: ED Course and Interventions

MEDICATION AND IV ORDERS

Time Solution, Additive Amount or Route Site Catheter Pump Rate By Time Amount Byinitiated or Medication Dose size (ini) DCed infused (ini)

Td or specify: 0.5cc Man: Lot #:

Si

te code 1. Deltoid 2. Gluteal 3. Anterior thigh 4. Lateral thigh 5. Antecubital fossa 6. Forearm 7. Hand 8. Foot 9. Neck 10. Intraosseous

NOTIFICATION

Time NURSES NOTES Ini

Caregiver # 1 Ini Caregiver # 3 Ini


DISPOSITION

Discharged LWBS AMA Expired Admitted Transferred to: _________________________ Transfer form completed

Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________________

Condition on D/C: Pain scale: ___________ NA Improved Worsened Good Fair Poor Stable Unstable Critical

Verbalizes understanding of discharge instructions Barriers to understanding or learning __________________________________

Written Verbal instructions given to: Report called by: _____________________________ _____:_____

Patient Parent Caregiver ___________________________ Report called to: _____________________________ _____:_____

Referred to: PRN / in da s D/C ed b : :

Time T P RR BP O2 Sat Pain

Weight_____________ lb. kg.

Family Nursing home PCP __________________ Other

Police Pastoral care Social Services

:

:

OTHER INTERVENTIONS

TRAUMA / SURGICAL

C-collar applied _________________

Ortho care ______________________ Ice Elevation

Ace Sling Splint Brace

Shoulder immobilizer StrappingKnee immobilizer Shoe

Crutch education

Wound care:

Topical anesthesia _____________ Wound prep _______________ ___

Adhesive ____________________

Suturing Staple _____________

Burn care ______________________

Fracture care ___________________

I and D ________________________

Arthrocentesis __________________

Chest tube _____________________

CARDIOPULMONARY

O2: ______ L NC Mask NRBPulse ox: Spot Continuous

Monitor ________________________Rhythm strip ____________________

EKG: ED EKG techIntubation ______________________CPR ACLS ______________ _____

Cardioversion ___________________External pacemaker ______________CVP placement _________________

Respiratory treatment _____________Sputum collection _______________IV thrombolysis _________________

ABDOMINAL / PELVIC

NG: Size _____ ________________Gastric lavage: NG Oral

Foley: Size _____ ______________I and O urine cath ________________Vomiting management ____________

Incontinence management _________Disimpaction ___________________Enema Type ____________________

Sexual assault exam ______________

EYE / ENT

Topical anesthesia _______________Eye irrigation _____cc of __________Ear wax/FB removal _____________Nasal FB removal _______________

Epistaxis control ________________

Laryngoscopy ___________________

PATIENT SUPPORT

Emotional support given

Learning needs addressedTranslation services provided

Post mortem care provided

MISCELLANEOUS

Lab draw: ED Lab techXR: Patient departed

Patient returned

Injection X 1 2 3 4

Restraints: 2 3 4 point

Reassessment _________________

Lumbar puncture ________________

Blood transfusion ________________

Conscious sedation ______________

Isolation for ____________________

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:

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:

Your Hospital Address

SAINT JOSEPH HOSPITAL

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Vital Signs

Serial vital signsand pain scale

documentation

Easily record all

Medicationsand

IV Orders

Notificationreminders

:

OTHER

______________________________

______________________________

:

:

APC

970

24-26

14-16

43-44

6-7

40

70

99

94

94

94

94

32

77-78

360

340

251250

71-72

359

210

110

APC codare includto prompcoders to

captureappropria

billing da

Easily anrapidly

record almany ED

interventiosaving th

need forexcessiv

nursing no

Disposition

Necessary

discharge itemsthat serve as

reminders andare easily

recorded

Raising the bar in documentation excellence!

19992004 ePowerDoc, Inc.


5/14

NursingDoc Design

The nursing templates have been designed to flow the way the emergency nurse

practices. All are two-paged documents.

Organization is consistent throughout each of the templates, producing learnability

and memorability.

Page 1

The first page is the Initial Nursing Assessmentspage. It includes Triage(with a separate,

easily identifiable area for Triage Vital Signs and Patient Acuity), Nursing History, Nursing

PhysicalExamination, NursingDiagnosis, and NursingPlan. A separate area for

Additionalassessments(Domestic violence and Alcohol screening) is available. Finally, an

area for recording InitialOrders and Interventionsprior to evaluation of the physician is

included. The charts are completed in the same manner as are PhysicianDoc charts.

Page 2

The second page is the ED Course and Interventionspage. Areas are available to easily

record Serial Vital Signs, Medications and IVs, Notifications, Nursing Notes, and

Disposition. Numerous reminders help the nurse to minimize missing important information,

as well as assure that all appropriate JCAHO documentation requirements are met. Aseparate area is available to record numerous emergency department Interventions. This not

only reduces the need for excessive writing, but also provides documentation to aide the

hospital coder in assessing appropriate APC assignments. A separate column is included

listing many of the potential additional APCs. This simplifies the assignment of these codes

by your coders.


6/14


7/14

Timing: Onset ____________ Minutes Hours Days Weeks Months ago

Came on: Suddenly Gradually Pain: Still present Worsened Improved Resolved

Location: R L Generalized Frontal Occipital Parietal Temporal Retroorbital

Severity: Mild Moderate Severe Like previous headaches Worst headache of lifeOther triage history:

_ _________Signatu__________________________

PRIMARY ASSESSMENT: Time: 8 : 57

Nursing history: Triage assessment reviewed

Source: Patient Family Friend Guardian Nursing home Paramedic Police InterpreterContext: Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposure

Associated signs and symptoms: None

Fever N V Weakness Numbness Photophobia Blurred vision

Nasal congestion Lacrimation Aura: Visual Sensory Motor MoodOther history:

Nursing exam:

Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsive

Respiratory: R L Bil Generalized Superior Inferior Wheezes Rales Rhonchi normal

CV: Tachycardia Bradycardia Irregular normal

Neurologic: Oriented to: Time Person Place Not oriented Unable to test normal

Motor function: R L Arm Leg Face Weak Unable to test normalOther exam:

__________Signatu__________________________

Medications: None

Allergies: None

TRIAGE: T 200/105 P 104 RR 24 BP 200/105 O2 Sat % 98 RA O2 GCS__________ Wt__________ lbs kg

Prehospital: Medic unit Vital signs: T P RR BP / O2 Sat % Monitor Accucheck

IV: type/amt infused cc Immobilization Medications

Source: Patient Family Friend Guardian Nursing home Paramedic Police InterpreterMode of arrival: Walk in Wheelchair Friends Attendant Ambulance Helicopter Police

TRIAGE DISPOSITION

WR Minor ED#

TRIAGE ACUITY

1 2 3 4 5

PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia High lipids Neuro: CVA DementHeart: MI Angina CHF CAD Lungs: COPD Asthma GI: PUD GERD Live

GU: UTIs Stones MS: Arthritis Psych: Depression Anxiety Schizophrenia Non

Operations: Appendectomy Cholecystectomy PTCA CABG None

Immunizations: Tetanus: UTD > 5 years Unknown

Other:

SH: Smoke: Current Past Second-hand Neve

ETOH: Social Abuse Alcoholic NonIllicit drugs: Non

Lives with: Mom Dad Spouse Family SO Alone

Lives in: Home Assisted care Homeless


Date: 9 / 10 / 05 Time: 8 : 50 Return visit: Same day Within 48CC:HEADACHE

TRIAGE INTERVENTIONS

O2

C-collar Ice Splint(s) Backboard

Mary Pierce


Are you in a relationship in which you havebeen physically hurt or threatened by your

partner?


Do you feel safe in your current environmen


Notification per protocol

Nutritional screening

Have you had an unexpected weight gain or

loss over 20 pounds in the last 6 months?


Are you on a special diet?


Nutritional referral given

Functional screening

Do you have trouble taking care of yourself

with feeding, dressing?


Do you fall unexpectedly or frequently?



PRIMARY ASSESSMENT INTERVENTIONS:

Dr/PA/NP notified 9 : 05

O2: ______L per: NC Mask NRBM :

SaO2 % on: RA O2 :

C-collar: Applied by __________ :

Removed by __________ :

Monitor/Rhythm: :

Orthostatics (recorded in Vital Signs section) :

EKG :

X-Ray: Port To Dept :

Blood draw: with IV Nurse Lab tech ;

Glucometer ____________ ;

IV 1 Solution Location Rate


Urine Dip :

Nebulizer/MDI :

Red rails: Up Down :

Call light :

Elevate HOB :

Restraints (see documentation) :

Ice Elevate Splint :

Suicide/Homicide precautions :

Cooling measures Warming measures :

Cleanse/Dress wounds :

VA R 20:_______ L 20:_______ B 20:_______

NURSE ADULT SAMPLE

-NOT FOR USE, COPYING, OR DISTRIBUTION-

WE CUSTOMIZE YOUR CHARTS TO MEET

YOUR NEEDS

Sandy Johnson

YOUR HOSPITAL LOGO HERE


8/14

MEDICATION AND IVS

Time Solution, Additive Amount or Route Site Catheter Pump Rate By Time Amount By initiated or Medication Dose size (ini) DCed infused (ini)

9:15 NS L5 18 g TKO

9:20 Morphine sulfate 4 mg IV L5

Td or specify: 0.5cc

Site code 1. Deltoid 2. Gluteal 3. Anterior thigh 4. Lateral thigh 5. Antecubital fossa 6. Forearm 7. Hand 8. Foot 9. Neck 10. Intraosseous

Oral

SECONDARY ASSESSMENTS

Time T P RR BP O2 Sat Pain Rhythm Status* INI Orthostatic (Tilt) Test

9:15 180/90 8 NSR NC I W MP BP P Tim

9:40 190/94 4 ST NC I W MP

11:00 166/80 3 NC I W

NC I W

NC I W

NC I W

cc Blood cc Urine cc Blood cc

IV cc Total cc NG cc Total cc


9:05 Dr. Faylor in to see patient MP

9:30 Lumbar puncture by Dr. Faylor MP

10:20 Called for bed MP


PATIENT/FAMILY EDUCATION

DISPOSITION

Discharged LWBS AMA Expired Admitted Transferred to: ______________________ Transfer form completed

Valuables with: Patient Family Friends Security Envelope #___________ Other ______________________________

Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________Condition on D/C: Pain scale: 3 NA Improved Worsened Good Fair Poor Stable Unstable Critical

Report called by: Mary Pierce : Referred to: _________________________PRN / in ________ days

Report called to: Sue Simmons 11 : 20 D/C ed by:

___________________________ _____:_____

NC I WOTHER INTERVENTIONS

NOTIFICATIONS

N OUT

Crutch training Wound care Written Verbal Discharge Instructions given to:

Walker training Ortho care Patient Parent Other

Safety issuesFoley care Verbalizes understanding of discharge instructions

* NC: No changeI: Improved

W: Worsened

TRAUMA / SURGICAL

C-collar applied

Ortho care


Shoulder immobilizer Strappi

Knee immobilizer Shoe

Crutch education

Wound care

Topical anesthesia

Wound prep

Adhesive

Suturing Staple

Burn care

I and D

Chest tube

:

:

:

:

:

:

:

:

:

:

:

:

:

:

CARDIOPULMONARY

O2: ______ L NC Mask NRB

Pulse ox: Spot Continuous

Aerosol treatment

EKG: ED EKG tech

Intubation

External pacemakerCentral line

:

:

:

:

:

::

GI / PELVIC

NG: Size _____

Foley: Size _____

Gastric lavage: NG Oral

I and O urine cath

Pelvic exam

:

:

:

:

:

MISCELLANEOUS

Lab draw: ED Lab tech

XR: Patient departed

Patient returned

Restraints 2 3 4 point

Reassessment

Lumbar punctureBlood transfusion

Isolation for

9 : 24:

:

:

:

9 : 30:

:

OTHER

:

SAFETY

Clinical alarm Y N

Side rails Y N

Call light Y N

Procedural pause N/A Y N

9 : 08:

:

:

:

:

:

:

:

:

:

Family:

Nursing home:

Pastoral care:

PCP:

Police:

Social services:

Other:

1999-2005 ePowerDoc, Inc.


9/14

Timing: Onset ____________ Minutes Hours Days ago

Duration: Since onset, fever has been: Constant Intermittent Daily Nocturnal

Severity: Fever: Questionable Subjective or _____________T max Oral Rectal Axillary


Respiratory: Cough Congestion Sore throat Dyspnea None

GI: Abdominal pain N V D None Oral in: Decreased Normal

Urinary: Dysuria Frequency Urgency None Urinary out: Decreased Normal

#_____________vomiting/24 h #_____________ diarrhea/24h #_____________diapers/12h

Other triage history:

____________________________________Signatu

PRIMARY ASSESSMENT: Time: :


Source: Patient Family Friend Guardian Nursing home Paramedic Police Interpreter

Context: History of : Immunosuppression Recent infection ___________________ Abx:____________________

Recent: URI Sore throat UTI Otitis media Gastroenteritis None

Exposure to known disease (specify): None

Associated signs and symptoms: NoneChills Rash Crying Irritability Fussiness Decreased activity None

Other history:

Nursing exam:

Constitutional: Alert Smiling Playful Ill-appearing Irritable Poorly responsive

Respiratory: R L Bil Generalized Superior Inferior Wheezes Rales Rhonchi normalCV: Tachycardia Bradycardia Irregular normal

Skin: Turgor: Decreased Rash: Location: normal

Neurologic: Alert Consolable Tracks Agitated Inconsolable Poorly arousable

Motor function: Sits Walks Decreased tone Flaccid normal for age

Other exam:

____________________________________Signatu

Medications:

Allergies:

TRIAGE: T_________ P_________ RR_________ BP____________ O2 Sat_________ % RA O2 GCS__________ Wt__________ lbs kg





Dr/PA/NP notified :


SaO2 % on: RA O2 :


Removed by __________ :

Monitor/Rhythm: :


EKG :






PMH: Birth weight: _________ kg/lb Hospitalizations: _________________________Non

Shots: Current Unknown Not current: DPT Hib Hep B OPV MMR Varicel

Medical: Prematurity FTT Asthma DM Recurrent UTIs Recurrent otitis

Esophageal reflux Cancer ____________________________________Non

Operations / Other

SH: Smoke: Current Past Second-hand Nev

ETOH: Social Abuse Alcoholic No

Illicit drugs: No


Attends Da care


Urine Dip :

Nebulizer/MDI :


Call light :

Elevate HOB :






VA R 20:_______ L 20:_______ B 20:_______

Date: / / Time: : Return visit: Same day Within 48 hourCC:PEDIATRIC FEVER

TRIAGE DISPOSITION

WR Minor ED#

TRIAGE ACUITY

1 2 3 4 5


O2


Pain Scale

Abuse screening

Evidence of abuse / neglect? Yes N



Current weight

*Length/Height

*Head circumference

*Birth weight

*Formula

*If less than 1 month gestational age or ED

physician request.


Developmental age appropriate? Yes N


NURSE PEDS SAMPLE

-NOT FOR USE, COPYING, OR DISTRIBUTION-

WE CUSTOMIZE YOUR CHARTS TO MEET

YOUR NEEDS

YOUR HOSPITAL LOGO HERE


10/14

MEDICATION AND IVS




Oral



NC I W BP P Tim

NC I W

NC I W

NC I W

NC I W

NC I W






DISPOSITION



Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________Condition on D/C: Pain scale: ___________ NA Improved Worsened Good Fair Poor Stable Unstable Critical

Report called by: _________________________ _____:_____ Referred to: _________________________PRN / in ________ days

Report called to: _________________________ _____:_____ D/C ed by:

___________________________ _____:_____

NC I W

OTHER INTERVENTIONS

NOTIFICATIONS

N OUT



Safety issuesFoley care Verbalizes understanding of discharge instructions

TRAUMA / SURGICAL

C-collar applied

Ortho care




Crutch education

Wound care

Topical anesthesia

Wound prep

Adhesive

Suturing Staple

Burn care

I and D

Chest tube

:

:

:

:

:

:

:

:

:

:

:

:

:

:

CARDIOPULMONARY



Aerosol treatment

EKG: ED EKG tech

Intubation


:

:

:

:

:

::

GI / PELVIC

NG: Size _____

Foley: Size _____


I and O urine cath

Pelvic exam

:

:

:

:

:

MISCELLANEOUS



Patient returned


Reassessment


Isolation for

:

:

:

:

:

::

:

OTHER

:

:

:

:

:

SAFETY

Clinical alarm Y N

Side rails Y N

Call light Y N



W: Worsened

:

:

:

:

:

:

:

Family:

Nursing home:

Pastoral care:

PCP:

Police:

Social services:

Other:

1999-2005 ePowerDoc, Inc.


11/14

NursingDoc

Customization Options Confidential Information

We recognize that every emergency department functions differently, and we have designed our

templates so that they may be customized to fit your departments unique needs. Below are the

areas in which customizations may be made:

[All areas shown in red on following sample template can be customized to your

specifications]

1. Patient identification area

2. Hospital name

3. Past history, Medications and Allergies

4. Page 1 Right Column (This entire column can be modified according to your needs.

Also, the information for the Adult can be different than that of the Pediatric.)

5. Page 1-- The Primary Assessment Interventions section can be changed to yourspecifications.

6. Page 2 -- The Secondary Assessments, Medication and IVs, Patient/FamilyEducation, and Disposition sectionscan be modified to your specifications.

7. Page 2 -- Other Interventions column - This entire column can be modifiedaccording to your needs.

8. Other Options

We can design a customized stand alone Orders Sheet for you. Although thePhysician templates already have a section available for Orders, many facilities

desire a stand-alone Orders sheet as well. This Orders sheet can printed on

demand, or each time you print a Physician template (if you are purchasingphysician templates), or each time you print a Nurse template.

Should you have additional requests for customizations, we will may everyattempt to accommodate these requests.


12/14


13/14


PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia High lipids Neuro: CVA DementHeart: MI Angina CHF CAD Lungs: COPD Asthma GI: PUD GERD Live

GU: UTIs Stones MS: Arthritis Psych: Depression Anxiety Schizophrenia Non

Operations: Appendectomy Cholecystectomy PTCA CABG None

Immunizations: Tetanus: UTD > 5 years Unknown

Other:

SH: Smoke: Current Past Second-hand Neve

ETOH: Social Abuse Alcoholic NonIllicit drugs: Non


Lives in: Home Assisted care Homeless

CC:CHEST PAIN

Timing: Onset: ____________ Minutes Hours Days ago

Location: Substernal R L chest

Radiation to: Abdomen Back Neck Jaw R L : Shoulder Arm Hand None

Quality: Sharp Stabbing Squeezing Pressure-like Heavy Crushing Burning AchingSeverity: Mild Moderate Severe or __________/10

Context:

History of: MI Angina Angioplasty Cardiomyopathy Valve disease DVT/PE None

Similar pain in past (diagnosis): ___________________________________________Other triage history:

PRIMARY ASSESSMENT: Time: :


Source: Patient Family Friend Guardian Nursing home Paramedic Police Interpreter

Duration: Since onset Intermittent or ____________ Seconds Minutes Hours Days


SOB Palpitations Diaphoresis Abdominal pain N/V Calf pain or swelling Chest rashOther history:

Nursing exam:

Constitutional: Alert Well-appearing Ill-appearing In distress Poorly responsive

Respiratory: R L Bil Generalized Superior Inferior Breath sounds: Diminished normal

CV: Tachycardia Bradycardia Irregular normalSkin: Cool Pale Diaphoretic normal

Neurologic: Oriented to: Time Person Place normal

Other exam:

Medications:

Allergies:

TRIAGE: T_________ P_________ RR_________ BP ____________ O2 Sat _________ % RA O2 GCS__________ Wt__________ lbs kg




TRIAGE DISPOSITION

WR Minor ED#

TRIAGE ACUITY

1 2 3 4 5


Are you in a relationship in which you have

been physically hurt or threatened by yourpartner?


Do you feel safe in your current environmen




Have you had an unexpected weight gain or

loss over 20 pounds in the last 6 months?


Are you on a special diet?


Nutritional referral given


Do you have trouble taking care of yourself

with feeding, dressing?


Do you fall unexpectedly or frequently?



This column is customizable and wil


Dr/PA/NP notified :


SaO2 % on: RA O2 :


Removed by __________ :

Monitor/Rhythm: :


EKG :






Urine Dip :

Nebulizer/MDI :


Call light :

Elevate HOB :






VA R 20:_______ L 20:_______ B 20:_______

Date: / / Time: : Return visit: Same day Within 48 hour


O2


____________________________________Signatu

____________________________________Signatu


14/14

MEDICATION AND IVS




Oral



NC I W BP P Tim

NC I W

NC I W

NC I W

NC I W

NC I W






DISPOSITION



Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________Condition on D/C: Pain scale: ___________ NA Improved Worsened Good Fair Poor Stable Unstable Critical

Report called by: _________________________ _____:_____ Referred to: _________________________PRN / in ________ days

Report called to: : D/C ed by: :

NC I WOTHER INTERVENTIONS

NOTIFICATIONS

N OUT



Safety issues Foley care Verbalizes understanding of discharge instructions

TRAUMA / SURGICAL

C-collar applied

Ortho care




Crutch education

Wound care

Topical anesthesia

Wound prep

Adhesive

Suturing Staple

Burn care

I and D

Chest tube

:

:

:

:

:

:

:

:

:

:

:

:

:

:

CARDIOPULMONARY



Aerosol treatment

EKG: ED EKG tech

Intubation


:

:

:

:

:

::

GI / PELVIC

NG: Size _____

Foley: Size _____


I and O urine cath

Pelvic exam

MISCELLANEOUS



Patient returned


Reassessment


Isolation for

:

:

:

:

:

::

:

OTHER

:

:

:

:

:

:

:

:

:

:

SAFETY

Clinical alarm Y N

Side rails Y N

Call light Y N



W: Worsened

:

:

:

:

:

:

:

Family:

Nursing home:

Pastoral care:

PCP:

Police:

Social services:

Other:

Documents

nursingdocbrochure_b4a36f44a8f1f.pdf