That would be NNH in this case.
Anyone any documentation tips? Pretty anxious about it for some reason.
1) A common issue I see with a lot of interns (and not only interns) notes is writing up very detailed, well written histories and physicals, and then writing up bare bones A/Ps. The priority should be on the medical decision making section. For example:
A: Chest pain.
P:
-CXR
-ECG
-Trop x 2
-DC
...is not sufficient. You should have at least a couple of different diagnoses that you considered and ruled out in your assessment. You don't have to have done tests on them, just documented that you thought about it and decided you were not clinically concerned. For example:
A: Chest pain, not exertional. Not concerned for PE given lack of risk factors and PERC negative. Not concerned for dissection given mild nature, rapid improvement, and overall clinical picture. No signs of Pneumonia. Overall low concern for ACS, but will get troponin x 2 to r/o MI and patient says will follow up with PMD tomorrow. Patient agreeable with plan.
P:
-CXR
-ECG
-Trop x 2
-DC
2) Always add a reassessment exam before discharge. It doesn't have to be a full physical, or anywhere near it. Just a brief note saying:
"Patient now clinically sober, steady on feet, eating turkey sandwich, asking to be discharged"
or
"Abdomen still soft, not tender, not distended, CT negative and discussed with patient, tolerated PO, will DC."
is sufficient. Same applies if the patient is boarding in your ED for a very long time, awaiting hospital admission, or whatever.
3) After those two, the most important piece of documentation, in my opinion, is the discharge instructions to the patient. The premade stuff so many EDs make you print to give to patients is largely useless. The one sentence you write down as the bottom line of what the patient should do after leaving the ER might be useful. Both to the patient and to you, medicolegally. So make sure it is written in a way that will look good in the retrospectroscope and is difficult to misinterpret. These are verbatim some things I've seen interns write as discharge instructions:
"Return to ER PRN."
"Return for NVD."
"RTC 2-4 weeks."
In other words don't use abbreviations, spell out things that seem to be obvious and give specific time courses. If you can, spell out what your findings were in the ED. For example:
"We did not find a cause for your chest pain today. Please follow up with your primary doctor within 2-3 days for re-evaluation and possibly further testing. If your symptoms return, worsen, change, please come back to the ER immediately."
4) It helps to have macros to type out a lot of these things for you. Most EMRs will have some useful shortcuts available, but well hidden. Find some attending who seems somewhat tech savvy and ask him or her how they do it.
