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Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Emergency Department Technician Documentation (1.0)

Emergency Department Technician Documentation (1.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

1.0




Effective Date:
April 10, 2017

ED Policy
Manual
Policy #: _1.0_______
Original
Revision x
Page 1 of 2 Emergency Department
Technician
Documentation




I. Purpose
To ensure that care provided by Emergency Department Technicians (EDTs) is appropriately
documented in the electronic health record (EHR). Clear documentation provides continuity of
care through effective communication with all health care personnel.

II. Policy
All patient care and interactions requiring documentation should be entered in the EHR as soon
after occurrence as possible.

III. Procedure
As a member of the health care team, the EDT will:

1. Assign self to the treatment team on the electronic Track Board, upon initial contact with
the patient, once the patient is assigned to a room or is in Carestart/FCA

2. Accurately document all information obtained and cares provided in the Emergency
Department (ED) .
a. Document all tasks attempted or completed and interventions provided to the
patient such as:
i. Vital signs
ii. IV insertions
iii. Observer checklists (i.e. foley insertions)
iv. Lab draws
v. Application of soft splints and other orthopedic procedures (as directed by
the RN or MD)
vi. Patient education (crutch walking)
vii. Visual acuity
viii. Comfort measures
ix. Completed ECG and who reviewed the ECG (ED attending physician)
b. Document all vital signs including pulse oximetry (if applicable). Document all
Intake and Output (I & O) in the EHR.
c. Document transport of ED patient for admission and belongings checklist.
d. Transporting and assisting patients (e.g. wheelchair)
3. Document vital signs and the status of patients in the patient care areas, and internal and
external waiting rooms when performing required regular rounding.
a. Regular rounding on assigned patients is documented in either:
i. Patient Status in EHR
ii. Narrative note in EHR IF information requires more explanation




Effective Date:
April 10, 2017

ED Policy
Manual
Policy #: _1.0_______
Original
Revision x
Page 2 of 2 Emergency Department
Technician
Documentation


b. Report changes and other pertinent information to nursing staff

IV. UWHC Cross Reference

A. Documentation in the Inpatient’s Clinical Record, UWHC Policy # 13.14

B. Ambulatory nursing staff roles and responsibilities, UWHC Policy # 2.02





V. Reviewed by

Clinical Nurse Specialist, Emergency Department
Director, Emergency Services
ED Clinical Operations
Nurse Managers, Emergency Department




SIGNED BY

Anne Rifleman, RN
Director, Emergency Services

Val Mack, RN
Co-Manager ED

Anne Rikkers RN
Co-Manager ED,