|
Emergency Medicine at HCMC
- The senior residents rely on your documentation to
dictate and write their chart. This blue paper is not an official document
but be thorough. Vital signs should be recorded every 2-5 minutes or
as often as possible. Document all procedures, medications given, IV
lines placed, physical exam findings, and any history available.
- Ask
what is being done if the nurses or residents are not telling you.
They should be talking to you, but you also need to talk to the people
caring
for the patient. Give the first vital signs out loud and any changes
or trends in the vital signs need to be communicated
- Labs – when
you are handed the lab sheet tell the senior the results.
- Intubation – the
time from the blade in until the blade out needs to be recorded in
seconds. Once the paralytic is given by the nurses count out the time
in 10 second
intervals.
- Recording the case allows you to see what goes on for the
whole case, be as involved as possible and communicate with the physicians
and nurses.
- An example of proper stab room recording is provided
on this page: Stab Room Recording
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.
|
