Without slowing you down…
Sean’s TOP 5 Every patient:
1) Vital Signs: Never ignore them, and never discharge an abnormal one (without a good reason!)
2) Nursing Notes: Read them, and explain any contradictions
3) Reexamination: Document a reexamination on every patient in plain language
4) Shared Decision Making: “Mr. Jones and I discussed the risk benefit of admission for his chest pain today, however, he and I are comfortable with him being discharged on an aspirin and following up for an outpatient stress”
5) Be nice!
For vital signs, make sure there is a second set of them unless you have done the most basic of interactions… like a medication refill. Have a second set of vital signs if you did anything that would change hemodynamics: blood pressure medications, normal saline, pain control. If your nursing staff is on top of things, this is something that should get done on every patient. The provider should then document that they interpreted the second set of vital signs!
On your re-examination, a very high yield statement is to say that “the patient appeared nontoxic at the time of disposition.”
I would also note that your patient is ambulatory and tolerated PO in the ED if you saw them. It gives a good overall picture of how your patient was doing to someone that is reading your note later.
Totally agree. You would think there is a database somewhere of “useful documentation phrases” that we could pull from.
Great info, the nursing notes are not always easy to find in every EMR, good points!