Info for Students: ER Chart Flow

[docB]

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People are always asking how they can be better prepared for their ED rotation. One thing you need to know by the end of your orientation at the latest is how the chart flow works in your ED.

In most EDs when triage rooms a patient the nurse puts the chart somewhere so the doc knows it is a patient to be seen. The "To Be Seen" position is usually a rack or slot. The doc then sees the patient and puts the chart in the "Orders" spot which is often in front of the unit clerk. The clerk then gets the chart back to the nurse. When all the labs and xrays are back the nurse then puts the chart in the "Re-eval" spot so the doc knows it's time to check the labs and dispo the patient. The doc usually then gives the chart back to the clerk who records the dispo and orders a bed if needed then it goes back to the nurse who discharges the patient or starts the admitting orders.

Triage-To Be Seen-Clerk-Nurse-Re-eval-Clerk-Nurse-Dispo is the usual order. Most EDs have some permutation of this scheme.

Electronic charts blur the lines because the charts don't physically move around but these steps are still there.

Note that there may be special considerations such as a seperate place where the Fast Track or Trauma charts pop up and to get the stuff you want ordered properly you may have to get the chart to the clerk of the right area of the ED. You've got to know the flow to effectively do anything in the ED.

 

[basementbeastie]

despite that orderly flow --> i still can never seem to find the chart when i need it!!!!!😕 😕 😕

 

[Wackie]

How it really goes:

Patient's name pops up on computer screen. Doctor takes care of other things to allow time to transfer from triage to room. Doctor goes to get chart. Chart is not in "Doc to see" slot. Looks for chart in assigned room slot. No chart. Doctor looks over most of the counters. No chart. Doctor thinks "screw it" and goes to the room. Patient is not there yet. Doctor goes back to doctor's pod. Offers opinion to another doc about interesting x-ray/CT, etc. Doctor spots nurse with chart as they bitch to another nurse about something doctor doesn't care about at the moment. Doctor gets chart from nurse. Listens to a long drawn out speech about what the nurse dislikes about this particular patient. Doctor does best to glean a little about patient history/complaint from speech. Learns patient "is allergic to all antibiotics". Cocks an eyebrow thinking "that's a new one". Doctor reviews partially completed chart. Goes to room. Where is patient? Doctor leaves room and says "Where is patient?" to nurse. "Patient might have gone pee pee". Doctor goes back to doctor's pod while tightly clutching chart to chest (if chart is let go, it will never be seen again). Doctor goes back to room. Patient is there. Doctor examines. Doctor writes orders. Nurse stops doctor in hall to see what is ordered to save time. Doctor shows nurse. Doctor gives chart to unit clerk who sighs heavily about having to lift fingers to type. Unit clerk enters orders Puts chart in nurses order rack. Nurse starts orders. Doctor attempts to check on labs. Doctor wonders why labs aren't even in process yet. Wants to confirm doctor ordered labs. Looks in nurse's rack. No chart. Looks in unit clerk rack. No chart. Looks in patient room. No chart. Looks in nurses hands. No chart. "Where is chart?"
*shrug from nurse*
Tech passes by with chart. Doctor takes chart. Tech belly aches about what the patient in another room said/did/smells like...



[I'm just a scribe, but it's what I've observed so far. A little stretched, but is what it feels like some days.]

 

[Apollyon]

It sounds like you spent time in the ED I trained in (except the charts are on the computer, but the orders are handwritten).

 

[Hard24Get]

WAHAHAHAHA!

I'm glad I read this so I could truly appreciate the place where I am doing my EM rotation. EVERYTHING is computerized, pts show up either under the waiting room list or next to a room # once they are triaged, you right-click to assign the pt to yourself, and pt is in the room (unless they went pee-pee, but they were given a cup in case this incident should arise so at least your gathering data). All orders are computerized and nurses sign them and execute them quickly, x-rays and CTs are done rapidlyand dutifully called in, and you are free to peruse the pt's prior visits while you wait and/or do your electronic charting. 😍

I'm definitely going to a residency program that is all computerized - besides, my handrwritting sucks. 😳

 

[mfleur]

WAHAHAHAHA!

I'm glad I read this so I could truly appreciate the place where I am doing my EM rotation. EVERYTHING is computerized, pts show up either under the waiting room list or next to a room # once they are triaged, you right-click to assign the pt to yourself, and pt is in the room (unless they went pee-pee, but they were given a cup in case this incident should arise so at least your gathering data). All orders are computerized and nurses sign them and execute them quickly, x-rays and CTs are done rapidlyand dutifully called in, and you are free to peruse the pt's prior visits while you wait and/or do your electronic charting. 😍

I'm definitely going to a residency program that is all computerized - besides, my handrwritting sucks. 😳

Where is this place where things get done quickly?

 

[Dr.Evil1]

Electronic medical record is the way to go. Physician order entry scared the older docs but now that we are almost a year out I don't think anyone can imagine going back. It is nice to know that when you write an order it actually gets done instead of sitting on the chart for 30 min before anyone notices I have written it.

 

[docB]

So in terms of flow with electronic charts the same things happen with a few changes and it all happens on a computer screen. Students need to know how a new patient to be seen is designated. Order entry is sometimes done in the system, sometimes not. Somehow the chart will get flagged again when the work up is done and the patient needs to be dispoed.

 

[GeneralVeers]

Electronic medical record is the way to go. Physician order entry scared the older docs but now that we are almost a year out I don't think anyone can imagine going back. It is nice to know that when you write an order it actually gets done instead of sitting on the chart for 30 min before anyone notices I have written it.

We have an electronic order entry system. Unfortunately it's tied to the order "printing out" either at the nurse's station, X-ray or CT. That means if you get a lazy employee, they'll just tell you "it didn't print out" as an excuse for why the CT scan hasn't been done for 6 hours.