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Emergency Dept Documentation
Emergency Dept Documentation
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Created by Qualaris Staff
Emergency Department
Critical Access Hospital
Table of Contents
Audit Form
Audit Form
Emergency Dept Documentation
Required
Observed Date
Type of Chart
Sexual Assault
Other
Emergency Dept Documentation Checklist
Mark all as...
ESI Triage Level Performed
Yes
No
N/A
Chief Complaint Documented
Yes
No
N/A
Medication/Allergy List Completed
Yes
No
N/A
Pain Assessment Completed
Yes
No
N/A
Social History Completed
Yes
No
N/A
Arrival Mode Documented
Yes
No
N/A
Advanced Directives, if applicable
Yes
No
N/A
LMP Documented, if applicable
Yes
No
N/A
Immunization Status, if applicable
Yes
No
N/A
Fall Risk Documented
Yes
No
N/A
Primary Assessment Completed & Appropriate
Yes
No
N/A
Nursing Notes Reflect Pts Care (q 30 min)
Yes
No
N/A
Medications Documented with Reassessment
Yes
No
N/A
Pain Level Reassessed After Pain Med Admin
Yes
No
N/A
Vital Signs Reassessed Appropriately
Yes
No
N/A
Heplock Documented Insertion/Removal
Yes
No
N/A
Disposition Documented
Yes
No
N/A
Discharge Instructions Given
Yes
No
N/A
Pain Level Assessed Upon Discharge
Yes
No
N/A
Discharge Vital Signs Assessed
Yes
No
N/A
Med Reconciliation Completed
Yes
No
N/A
Summary of Care given, if applicable
Yes
No
N/A
