Emergency Room Documentation Templates: Fill & Download for Free

Is it a detailed initial assessment note or supplemental?… for supplemental, you mainly need to state current status and any new interventionFor a newly received patient note, use an SBAR form as cheat-cheat ( usually each facility has a guideline for documentation).Document facts alone- what patient said, what you measure during assessment and intervention provided)SituationBackgroundAssessmentRecommendation/intervention—current situation of the patient -Patient is a 5 year old with mild respiratory distress brought in by parent. As per parent, patient complained of getting short of breath while playing and parent noticed nasal flaring, which prompted emergency room visit.—HistoryWith history of autism, allergy to peanut.—Assessment (think most pressing issue, then head to toe) example —- patient is responsive, responds appropriately to verbal command (some may write—patient alert and oriented to time place and person), patient’s respiration of 35 breaths per minute at rest with mild subcostal retraction, good air entry into lungs. Decreased oral intake- refused all oral intake yesterday 3/3/16 and today. Decreased urine output- no void for past 15hours. No pain. Skin intact? ( include any body device).—Intervention ( what was done to improve parient’s status) oxygen therapy initiated at 4liters per minute of humidified O2, cardiopulmonary monitoring initiated, nothing by mouth, etc… education you provided.( These are just made up examples)… I am not an expert either but I’m always trying to keep my note short and accurate — in a way that I can look at the note and explain everything important that happened during my time with a patient. )As someone noted already— look for a documentation that looks really good to you— detailed and to the point, then use the template in your documentation. I see some new nurses do this until they feel more confident creating one offhand. I also read doctors notes.

I’ll tell this story cuz it’s kinda embarrassing but I can own it. — About a decade ago, I met up with someone in a hotel room and did some risky things, and the next morning I woke up with a tingly feeling that I had made a BIG mistake.Yes, that’s a burning sensation in my urethra. It did not take very long to happen.I got online and researched it; figured it was, without a doubt, gonorrhea — and, then went to my trusted physician, who would’ve prescribed me heroin by phone if I said I had a headache.This time, though — I went in and said, “I need a shot of ceftriaxone.”I explained my symptoms; he did a gentle little swab, and he sent that off to the lab. He didn’t treat anything immediately, which was really odd from my perspective. He always treated first.Years later, I would learn the CDC recommended treating first, and judging lab results later. Alas, I got the full experience of what my friend, who’s been there before, called drippy dick.It was hell. I had to drink lots of beer just to justify peeing. I’d never imagined such a pain.In the middle of the week, I called back to the doctor and said, I can’t handle this any longer. He prescribed me doxycycline, which is great for chlamydia. Alas. I knew that was not the problem, and the drug didn’t help.A week later, I got a call from the doctor, who said I needed to come back in. With a smile on his face, he told me I had gonorrhea, and I needed — go figure — a shot of ceftriaxone. He said the literature implied I should get about 100mg. However, he could only get the vials in 1 gram doses, so I had the choice to do the minimum, or he’d just give me all of it.Ya know, no waste.I said, gimme all of it, NOW.And, he did. Within 12 hours, I felt better and the episode was over.I have no idea why he didn’t treat me immediately, when all I was asking for was a simple antibiotic that — cummon — you didn’t need a degree in medicine to know was appropriate.The internet could tell me what I needed; the CDC said treat first. I asked for it.Making me wait a week — yeh, not smart. It’s not like I was asking for a Vicodin script, though honestly — IT WOULD NOT HAVE BEEN WASTED ON ME.The doctor asked that I sit in the waiting room for 15 mins after the injection, in case of allergic reaction. But I was not a risk for that anyway.He would have been smart to treat me immediately. And, as much as I love him, he screwed this one up. If I was as much a hoe as the diagnosis implies, I could’ve spread this to many, many folks while waiting on the lab results. This is, of course, why the CDC advises that you don’t wait on them.Of course, you’d have to be in the dark, or blind, or blind and lacking a sense of taste — I could go on — to miss a guy with gonorrheal urethritis. Apparently, though, a woman can go on with the infection for almost indefinitely and not know anything is wrong, and no one else knows either.That is… until 10 - 12 hrs later when, if you’re male, you really know. Considering my doctor was the city’s chief physician, I don’t know how he could’ve made such a rookie mistake on something as simple as an STI. The infection just continued to get worse, and it hurt “like the dickens,” as my ass doctor would say; he’s coming up in a moment (alas). — This is one of those reasons why I no longer trust physicians and practitioners implicitly.On another occasion I requested an oral antifungal specifically because it was not an azole antifungal — for a skin rash. Mixing oral azole antifungals with anxiety medications (i.e., benzodiazepines) leads to paradoxical effects from the benzos, like panic attacks and shortness of breath, which may end you up in the emergency room. Of course, the internet is not always excellent, and Lamisil doesn’t even treat the tinea I was going after. So, the doctor should have caught that. Verify the drug requested is a treatment for the rash before agreeing. — He brushed off the azole/benzo combination as no big deal, despite me saying I had, indeed, gone to the emergency room, where my oxygen saturation was measured to be in the high 80s (%), warranting a short period of observation but nothing major. He said the drug I’d found, and that he prescribed, was one of the best. For what? — A day or so later, I found where Lamisil does not treat the particular tinea in question. The actual answer was the contraindicated oral azole antifungal, messy topical azole creams, or live with a cosmetic defect. That last one worked just fine, — because I prefer breathing over the absence of a little red dot on my skin — and, I probably won’t see the rash until I receive a course of antibiotics again.Having to explain elimination half-lives of benzodiazepines to the nurse practitioner was fun. While what I was saying was true; a psychiatrist had helped me to understand why they’re important in anxiety management years before — for all the NP knew — I could have been describing playmate stats and batting averages. In her case, she was my age and rather new to practice, so I give her a pass. How a doctor who started practicing at least 15 years before I was born could have needed my input, — that’s beyond me.Oh yeah. I went to a gastroenterologist for butt pain. Man was super smart; I’d checked up on him, and he and his wife lived in a $1 million house in a city where $300,000 would be fancy. You know — only the best for my ass.We talked for a good while and decided a conservative course of action was best to try first, and that would involve a compounded salve containing nitroglycerin (BOOM-POW!) and lidocaine. Lidocaine was sort of a big deal, you know. My chief complaint was butt pain.When I got my prescription, he had a template form with several options, and it was made so he’d just circle which one he was ordering; sign the bottom, and ship the butt-issue patient out the door. Upon cursory inspection of the document — you know, I sack my own groceries for this same reason — I saw that he circled the wrong prescription salve. Just the BOOM-POW in it; no lidocaine.So, like in a restaurant, I had to send my order back and ask the chef to consider my steak was raw. — The nitro/lido salve works pretty well, for those who are interested.

Here are the key steps for building a solid sales process from scratch:Analyze your current sales processes and their performance to understand what your sales team is already doing and how effective it is.Map the buyer’s journey for every target persona to learn about the typical path your prospects follow to become your customers so you can match it to the existing sales process you’ve outlined earlier.Plan the activities for each process stage (and make sure to leave some room for experimentation, i.e. emerging sales methods or alternative engagement channels).Set measurable and realistic KPIs for each step of the sales process to add clarity to your process and make sure all of your team members are working toward the same goal.Allocate responsibilities within your team throughout the different stages of the process to make sure each involved party knows their role and works together with the others.Also, I would recommend including the sales tools – anything that can be used to orchestrate the activities at every step of your sales process – in the document. This will help you make sure your team members (especially the new ones) are aware of the available resources and can make the best use of them.If you’re looking for more a more detailed, hands-on guide (including free templates) check this - Beginner's Guide to Sales ProcessesHope this helps!