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Emerg Med Clin North Am. 2009 Nov;27(4):641-54, ix. doi: 10.1016/j.emc.2009.07.008.

Critical aspects of emergency department documentation and communication.

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1
Department of Emergency Medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street, Box 573, New York, NY 10065, USA. kty9001@med.cornell.edu

Abstract

This article focuses on the unique environment of the emergency department (ED) and the issues that place the provider at increased risk of liability actions. Patient care, quality, and safety should always be the primary focus of ED providers. However, the ED chart is the only lasting record of an ED visit, and attention must be paid to proper and accurate documentation. This article introduces the important aspects of ED documentation and communication, with specific focus on key areas of medico-legal risk, the advantages and disadvantages of the available types of ED medical records, the critical transition points of patient handoffs and changes of shift, and the ideal manner to craft effective discharge and follow-up instructions.

PMID:
19932398
DOI:
10.1016/j.emc.2009.07.008
[Indexed for MEDLINE]
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