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Written by Super User on . Posted in Uncategorised
CCR Information:
Documentation Do's & Don'ts:
| Documentation of: |
Do's |
Don'ts |
| Vitals |
- Multiple sets when needed
|
- Pressures without at least one baseline, full pressure
|
| Medications |
- List all meds taken by patient
|
- Leave spot on report blank
- Use "see list" without attaching a copy of the actual list
|
| Allergies |
- List all allergies including non-med allergies
- If patient has allergies list side effect and sensitivities etc.
|
- Leave spot on report blank
- Use "see list" without attaching a copy of the actual list
|
| PMH |
- List all medical history even if it does not appear to be relevant to the current event
|
- Leave spot blank on report
- Use abbreviations unless they are commonly accepted and known by all healthcare providers
- Leave out some items that you do not think are relevant to the current problem
|
| Times Recorded in Flow Chart |
- List times for each set of vitals, med administration, skill or procedure performed
|
- Leave times missing or only enter some times
|
| Name of Medical Control Physician |
- Give name of physician spoken to for on-line medical direction or put "Standing Orders" for off-line medical direction
|
- Leave spot on report blank
- Use terms such as "ER doctor"
|
| Stroke Protocol |
- Document a thorough neuro exam
- Perform the Boston Stroke Scale
- Document that the entry note nurse was advised that this patient warranted activation of the stroke team upon arrival to ED.
|
- Forget to activate the stroke team
|
| 12 Lead EKG |
- Perform a 12 lead on any patient suspected of having a cardiac event
- Attach all 2 lead and 12 lead strips to run report and QA copy of run report.
- Perform on diabetics with vague complaints
- Label with patient name, date etc.
|
- Forget to attach a copy of strips and 12 leads to QA copy of run report as well as copy left at facility
- Write 12 lead performed without attaching a copy
|
| DNR |
- Document contact with medical control for all DNR patients who are not treated to protocol
- Attach copy of DNR order to both run report and QA copy of run report
|
- Forget to attach copy of DNR to run report and QA copy of run report
|
| Blood Glucose |
- A B.G. on all altered mental status patients or diabetics who exhibit other complaints that could mask a hypoglycemic episode
- Document B.G. clearly on run report
- Remember to provide a before and after B.G. for suspected hypoglycemic patients
|
|
