UMEM Educational Pearls

Category: Med-Legal

Title: ED Documentation

Keywords: Documentation, Legal, Chart (PubMed Search)

Posted: 8/4/2007 by Michael Bond, MD (Updated: 7/18/2019)
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ED Chart Documentation ==> Provide documentation that you ruled out the worst possible outcome. ==> Read and acknowledge the nurse s notes especially if a conflict exists. ==> Always address abnormal vital signs. ==> Provide times for all notes. ==> Don t use demeaning terminology to describe patients. ==> Write interval progress notes when a patient s condition changes. ==> Document lab, EKG, and x-ray abnormalities. Disclaimer:This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.