Emergency Medicine at HCMC
The following is an example of a blank
visit record formerly used for the documentation of emergency care at
HCMC. I present it here to give a visual outline of what should
be included in the record of a properly documented Emergency Medicine
encounter. All patients need a HPI, ROS, Past medical family and
social history, & a physical examination documented. Additionally
any procedures done during the patients care should be documented. It
is also important to document a differential diagnosis along with a care
plan. Furthermore many patients will be continually reassessed
during their care. Patients with asthma are prime examples. Proper
care and documentation of such patients require that these interval assessments
be documented in their visit record. Currently HCMC uses Emstat
(our computerized medical record) to record patient care by the RNs and
MDs. Each piece of the record is entered on its own "smart
form" which will be demonstrated during orientation.
For more information contact Richard
O. Gray MD.
Emergency
Medicine main page
Copyright © 2000 HCMC Emergency Medicine. All rights reserved.
Manual last modified: Wednesday May 07, 2003.
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