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Captures all mandated screens,
including Disposition
Risk Management & APC Capture

Imbedded clinical prompters identify
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accurately and completely
Eliminates Chart Storage Problems

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NursingDoc
Prompts the nurse to rapidly document all data needed for a comprehensive medical record,
while at the same time meet JCAHO and CMS documentation requirements.
Page 1: INITIAL Assessments and Interventions
Chief
Complaint
SAINT JOSEPH H0SPITAL
PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia High lipids

Heart: MI Angina
GU: UTIs Stones
Neuro: CVA Dementia

Lungs: COPD Asthma
GI: PUD GERD Liver
Psych: Depression Anxiety Schizophrenia
None
None
see attached list ________________________________________
_______________________________________________________________________
_______________________________________________________________________
Allergies:
None Latex ___________________________________________________
Medications:
are easily
recorded
Triage vital signs
CC: HEADACHE
TRIAGE:
Pertinent
information to
determine triage
level
CHF CAD
MS: Arthritis
Recent hospitalization for: _____________________________________________

Other: _______________________________________________________________________
More than 120

unique adult
and pediatric
complaints
Triage
Past
Medical
History,
Medication
and Allergies
Emergency Department Nursing Record
Your Hospital Address
: am
pm
Mode of arrival: Walk in Wheelchair Friends Attendant Ambulance Helicopter Police

Source: Patient Family Friend Guardian Nursing home Paramedic Police Interpreter
Timing: Onset ____________ Minutes Hours Days Weeks Months ago
Came on: Suddenly Gradually Pain: Still present Worsened Improved Resolved
Location: R L Generalized Frontal Occipital Parietal Temporal Retroorbital
Severity: Mild Moderate Severe Like previous headaches Worst headache of life
Context: History of: Glaucoma Immunosuppression Bleeding diathesis None
Known headache disorder (dx): __________________________________None
Other history:
RR
O2 Sat
Pain
Wt
BP
Consistent areas
to record
kg
Triage vital
signs
lb
(including pain scale)
Triage acuity
Emergent
Urgent
and
Nonurgent
Triage Acuity
Other Assessments
Domestic violence screening
Are you in a relationship in which you have
been physically hurt or threatened by your
partner?
Y N Unwilling to answer
Nursing
Assessment
Succinct but
appropriate
nursing history
and physical
examination
Nursing
Diagnosis
_______________________________________Signature
NURSING ASSESSMENT:
Room:
: am
________
pm
Nursing history:
Triage assessment reviewed
Prehospital: CPR Intubation O2 IV C-collar Backboard Splints Meds _____________ None
Context: Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposure
Associated signs and symptoms: None
Fever N V Weakness Numbness Photophobia Blurred vision
Nasal congestion Lacrimation Aura: Visual Sensory Motor Mood
Other history:
Nursing exam:
Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsive
Respiratory: R L
Bil Wheezes Rales Rhonchi
CV: Tachycardia Bradycardia Irregular
Neurologic: Oriented to: Time Person Place Not oriented Unable to test
Motor function: R L Arm Leg Face Weak Unable to test
Other exam:
Alcohol screening
Do you drink alcohol?
Y N
During the last year have you had a feeling of
guilt or remorse after drinking?
Y N
During the last year has someone told you
about things you said or did while you were
drinking that you could not remember?
Y N
During the last year have you failed to do
what was normally expected of you because
of drinking?
Y N
Do you sometimes take a drink in the morning
when you first get up?
Y N
normal
normal
normal
normal
Pvt MD notified: YES
NO
Accucheck: __________________
O2: _________________________
Monitor ___________________
EKG
______________
XR: _______________________
Labs: _________________________
Potential infection
U preg: +
Control: +
NURSING PLAN: To appropriate area
Breathing treatments ________
EXPECTED OUTCOME: Pain control/Absent
Splint(s) ___________________
Dressing (s) __________________
_______________________________________Signature
1999-2001 ePowerDoc, Inc. v. 3.0
Completely
customizable
Design your
own or pick
from our
multiple options
Standing orders or interventions initiated

prior to physician evaluation:
IV: ________________________
NURSING DIAGNOSIS: Altered comfort: Pain
Optional
other assessments
Orders, Interventions, and Results
Nursing
Plan
Expected
Outcome
Do you feel safe in your current environment?

:
:
:
:
:
:
:
:
:
:
:
:
:
:
Tetanus (see medication section)

Circled = positive Not circled or / = negative
Lined out or section completely blank = not assessed
And your charts are customizable to meet your own individual needs!
19992004 ePowerDoc, Inc.
Standing
orders
or other initial
nursing
interventions
are easily
documented
Page 2: ED Course and Interventions
SAINT JOSEPH HOSPITAL
Time
RR
BP
O2 Sat
Pain
OTHER INTERVENTIONS
APC
Your Hospital Address
TRAUMA / SURGICAL
Vital Signs
Serial vital signs
and pain scale
documentation
Weight _____________ lb.
kg.
MEDICATION AND IV ORDERS

Time
initiated
Solution, Additive
or Medication
Amount or
Dose
Route
Site
Catheter
size
Pump
Rate
By
(ini)
Time
DCed
Amount
infused
By
(ini)
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
C-collar applied _________________

Ortho care ______________________
Ice Elevation
Ace Sling Splint Brace
Shoulder immobilizer Strapping
Knee immobilizer
Shoe
Crutch education
Wound care:
Topical anesthesia _____________
Wound prep __________________
Adhesive ____________________
Suturing Staple _____________
Burn care ______________________
Fracture care ___________________
I and D ________________________
Arthrocentesis __________________
Chest tube _____________________
:
:
:
:
:
:
:
:
:
:
:
:
O2: ______ L NC Mask NRB

Pulse ox: Spot Continuous
Monitor ________________________
Rhythm strip ____________________
EKG: ED EKG tech
Intubation ______________________
CPR ACLS ___________________
Cardioversion ___________________
External pacemaker ______________
CVP placement _________________
Respiratory treatment _____________
Sputum collection _______________
IV thrombolysis _________________
:
:
:
:
:
:
:
:
NG: Size _____ ________________

Gastric lavage: NG
Oral
Foley: Size _____ ______________
I and O urine cath ________________
Vomiting management ____________
Incontinence management _________
Disimpaction ___________________
Enema Type ____________________
Sexual assault exam ______________
:
:
:
:
:
Topical anesthesia _______________

Eye irrigation _____cc of __________
Ear wax/FB removal _____________
Nasal FB removal _______________
Epistaxis control ________________
Laryngoscopy ___________________
:
:
:
:
:
:
:
:
:
:
Lab draw: ED Lab tech

XR: Patient departed
Patient returned
Injection X 1 2 3 4
Restraints: 2 3 4 point
Reassessment _________________
Lumbar puncture ________________
Blood transfusion ________________
Conscious sedation ______________
Isolation for ____________________
:
:
:
:
Emotional support given

Learning needs addressed
Translation services provided
Post mortem care provided
:
:
______________________________
______________________________
Easily record all
CARDIOPULMONARY
Medications
and
IV Orders
Td or specify:
Site code 1. Deltoid
0.5cc
2. Gluteal
Man:
3. Anterior thigh
4. Lateral thigh
Lot #:
5. Antecubital fossa
6. Forearm
7. Hand
8. Foot
9. Neck
10. Intraosseous
NOTIFICATION
:
:
Notification
reminders
970
24-26
14-16
43-44
6-7
40
70
Family
Police
Nursing home
Pastoral care
:
:
PCP __________________
Social Services
:
:
Other
NURSES NOTES
Time
Easily and
rapidly
record almost
any ED
intervention,
saving the
need for
excessive
nursing notes
99
94
94
94
94
32
77-78
ABDOMINAL / PELVIC
Ini
360
EYE / ENT
Disposition
Necessary
discharge items
that serve as
reminders and
are easily
recorded
340
251
250
71-72
MISCELLANEOUS
Caregiver # 1
Ini
Caregiver # 3
Ini
Caregiver # 2
Ini
Caregiver # 4
Ini
DISPOSITION
Discharged
LWBS
AMA
Mode of departure: Walking
Expired
Carry
Admitted
Wheelchair
Condition on D/C: Pain scale: ___________
Transferred
Cart
NA
Auto
Improved
Verbalizes understanding of discharge instructions

Written
Patient
Verbal
Parent
to:
Worsened
MediVan
Good
Fair
Poor
Stable
Unstable
Critical
Report called by: _____________________________ _____:_____
Caregiver ___________________________
PRN / in
PATIENT SUPPORT
Transfer form completed
_________________________________________
Barriers to understanding or learning __________________________________
instructions given to:
Referred to:
_________________________
Ambulance
Report called to: _____________________________ _____:_____

days
D/C ed by:
OTHER
Raising the bar in documentation excellence!

19992004 ePowerDoc, Inc.
359
210
110
APC codes
are included
to prompt
coders to
capture
appropriate
billing data
NursingDoc Design
The nursing templates have been designed to flow the way the emergency nurse
practices. All are two-paged documents.
Organization is consistent throughout each of the templates, producing learnability
and memorability.
Page 1
The first page is the Initial Nursing Assessments page. It includes Triage (with a separate,
easily identifiable area for Triage Vital Signs and Patient Acuity), Nursing History, Nursing
Physical Examination, Nursing Diagnosis, and Nursing Plan. A separate area for
Additional assessments (Domestic violence and Alcohol screening) is available. Finally, an
area for recording Initial Orders and Interventions prior to evaluation of the physician is
included. The charts are completed in the same manner as are PhysicianDoc charts.
Page 2
The second page is the ED Course and Interventions page. Areas are available to easily
record Serial Vital Signs, Medications and IVs, Notifications, Nursing Notes, and
Disposition. Numerous reminders help the nurse to minimize missing important information,
as well as assure that all appropriate JCAHO documentation requirements are met. A
separate area is available to record numerous emergency department Interventions. This not
only reduces the need for excessive writing, but also provides documentation to aide the
hospital coder in assessing appropriate APC assignments. A separate column is included
listing many of the potential additional APCs. This simplifies the assignment of these codes
by your coders.
YOUR HOSPITAL LOGO HERE
Neuro: CVA Dementia

Heart: MI Angina CHF CAD
Lungs: COPD Asthma
GI: PUD GERD Liver
GU: UTIs Stones
MS: Arthritis
None
Operations: Appendectomy Cholecystectomy PTCA CABG
None
Immunizations: Tetanus: UTD > 5 years Unknown
Other:
NURSE ADULT SAMPLE

-NOT FOR USE, COPYING, OR DISTRIBUTION-
SH: Smoke: Current

ETOH: Social
Illicit drugs:
Lives with: Mom
Lives in: Home
WE CUSTOMIZE YOUR CHARTS TO MEET

YOUR NEEDS
CC: HEADACHE
Date:
/ 10
/ 05
Past Second-hand
Abuse
Alcoholic
Never
None
None
Dad Spouse Family SO

Assisted care Homeless
8 : 50
Time:
Alone
Return visit: Same day
Within 48
Medications: None
Allergies:
None
TRIAGE: T 200/105
Prehospital:
P 104
Medic unit
RR
24
Vital signs: T
BP 200/105
P
IV: type/amt infused cc
RR
O2 Sat %
BP
98
RA O2
O2 Sat
Immobilization
GCS__________
Wt__________ lbs kg
Monitor
Accucheck
Medications
Timing: Onset ____________ Minutes Hours Days Weeks Months ago
Came on: Suddenly Gradually Pain: Still present Worsened Improved Resolved
Location: R L Generalized Frontal Occipital Parietal Temporal Retroorbital
Severity: Mild Moderate Severe Like previous headaches Worst headache of life
Other triage history:
TRIAGE INTERVENTIONS
O2
C-collar
Ice
Splint(s)
Backboard
TRIAGE DISPOSITION
WR
Minor
ED #
TRIAGE ACUITY
Sandy Johnson
____________________________________Signature
PRIMARY ASSESSMENT:
Time:
8 : 57

Nursing history:
Context: Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposure
Fever N V Weakness Numbness Photophobia Blurred vision
Nasal congestion Lacrimation Aura: Visual Sensory Motor Mood
Other history:

partner?
Nursing exam:
Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsive
Respiratory: R L Bil Generalized Superior Inferior Wheezes Rales Rhonchi
Neurologic: Oriented to: Time Person Place Not oriented Unable to test
Motor function: R L Arm Leg Face Weak Unable to test
Other exam:
Notification per protocol

normal
normal
normal
normal
Nutritional screening
Have you had an unexpected weight gain or
loss over 20 pounds in the last 6 months?
Are you on a special diet?
PRIMARY ASSESSMENT INTERVENTIONS:

Dr/PA/NP notified
9 : 05
O2: ______L per: NC Mask NRBM
:
SaO2
% on: RA O2
:
C-collar: Applied by __________
:
Removed by __________
:
Monitor/Rhythm:
:
Orthostatics (recorded in Vital Signs section)
:
EKG
:
X-Ray:
Port To Dept
:
Blood draw: with IV Nurse
Lab tech
;
Glucometer ____________
;
IV 1 Solution
Location
IV 2 Solution
Location
Urine Dip
:
Nebulizer/MDI
:
Red rails: Up Down
:
Call light
:
Elevate HOB
:
Restraints (see documentation)
:
Ice Elevate
Splint
:
Suicide/Homicide precautions
:
Cooling measures Warming measures
:
Cleanse/Dress wounds
:
VA R 20:_______ L 20:_______ B 20:_______
Rate
Rate
Nutritional referral given

Functional screening
Do you have trouble taking care of yourself
with feeding, dressing?
Do you fall unexpectedly or frequently?

Mary Pierce
____________________________________Signature
SECONDARY ASSESSMENTS
Time
RR
BP
O2 Sat
Pain
Rhythm
Status*
Solution, Additive
or Medication
Amount or
Dose
9:15
NS
9:20
Morphine sulfate
4 mg
Route
IV
Orthostatic (Tilt) Test
9:15
180/90
NSR
NC
MP
9:40
190/94
ST
NC
MP
11:00
166/80
NC
NC
NC
NC
* NC:
NC
MEDICATION AND IVS

Time
initiated
INI
Site
Catheter Pump
size
L5
18 g
Rate
BP
I:
W:
Time
No change
Improved
Worsened
OTHER INTERVENTIONS
By
(ini)
Time
DCed
Amount
infused
SAFETY
By
(ini)
9 : 08
:
:
:
TKO
L5
Clinical alarm
Side rails
Call light
Procedural pause
N/A
Y
Y
Y
Y
N
N
N
N
TRAUMA / SURGICAL
Td or specify:
IN
0.5cc
2. Gluteal
3. Anterior thigh
4. Lateral thigh
Oral
cc
Blood
cc
IV
cc
Total
cc
OUT
6. Forearm
7. Hand
8. Foot
9. Neck
10. Intraosseous
Urine
cc
Blood
cc
NG
cc
Total
cc
NURSES NOTES
Time
Ini
9:05 Dr. Faylor in to see patient
MP
9:30 Lumbar puncture by Dr. Faylor
MP
10:20 Called for bed
MP
:
:
:
:
:
:
:
:
:
:
:
:
:
:
C-collar applied
Ortho care
Knee immobilizer
Shoe
Crutch education
Wound care
Topical anesthesia
Wound prep
Adhesive
Suturing Staple
Burn care
I and D
Chest tube
:
:
:
:
:
:
:

Aerosol treatment
EKG: ED EKG tech
Intubation
External pacemaker
Central line
:
:
:
:
:
NG: Size _____

Foley: Size _____
Gastric lavage: NG
I and O urine cath
Pelvic exam
CARDIOPULMONARY
GI / PELVIC
Oral
MISCELLANEOUS
Caregiver # 1
Ini
Caregiver # 2
9 : 24
:
:
:
:
9 : 30
:
:
Ini
PATIENT/FAMILY EDUCATION
Crutch training
Wound care
Walker training
Ortho care
Safety issues Foley care
Written
Verbal
Patient
Discharge Instructions given to:
Parent
OTHER
Other
DISPOSITION
Discharged
LWBS
AMA
Valuables with: Patient
Expired
Family

Condition on D/C: Pain scale:
Admitted
Friends
Carry
3
Wheelchair
Envelope #___________
Cart
NA
Auto
Improved
Report called by:
Mary Pierce
Report called to:
Sue Simmons
11 : 20
1999-2005 ePowerDoc, Inc.
NOTIFICATIONS
Transferred to: ______________________
Security
Ambulance
Worsened

Patient returned
Restraints 2 3 4 point
Reassessment
Lumbar puncture
Blood transfusion
Isolation for
Other ______________________________
MediVan _________________________________
Good
Fair
Poor
Stable
Unstable
Critical
Referred to: _________________________PRN / in ________ days

D/C ed by: ___________________________ _____:_____
:
:
:
:
:
:
:
Family:
Nursing home:
Pastoral care:
PCP:
Police:
Social services:
Other:
YOUR HOSPITAL LOGO HERE
PMH: Birth weight: _________ kg/lb Hospitalizations: _________________________None

Shots: Current Unknown Not current: DPT Hib Hep B OPV MMR Varicella
Medical: Prematurity FTT Asthma DM Recurrent UTIs Recurrent otitis
Esophageal reflux Cancer ____________________________________None
Operations / Other
NURSE PEDS SAMPLE

-NOT FOR USE, COPYING, OR DISTRIBUTION-
SH: Smoke: Current Past Second-hand

ETOH: Social
Abuse
Alcoholic
Illicit drugs:
Lives with: Mom Dad Spouse Family SO
Attends Day care
WE CUSTOMIZE YOUR CHARTS TO MEET

YOUR NEEDS
CC: PEDIATRIC FEVER
Date:
Time:
Never
None
None
Alone
Within 48 hours
Medications:
Allergies:
TRIAGE: T_________
Prehospital:
P_________
Medic unit
RR_________
Vital signs: T
BP ____________
P
RR
O2 Sat _________ % RA O2
BP
O2 Sat
Immobilization
GCS__________
Wt__________ lbs kg
Monitor
Accucheck
Medications
Timing: Onset ____________ Minutes Hours Days ago
Duration: Since onset, fever has been: Constant Intermittent Daily Nocturnal
Severity: Fever: Questionable Subjective or _____________ T max Oral Rectal Axillary
Respiratory: Cough Congestion Sore throat Dyspnea None
GI: Abdominal pain N V D None
Oral in: Decreased Normal
Urinary: Dysuria Frequency Urgency None
Urinary out: Decreased Normal
#_____________vomiting/24 h
#_____________ diarrhea /24h
#_____________diapers/12h
O2
C-collar
Ice
Splint(s)
Backboard
TRIAGE DISPOSITION
WR
Minor
ED #
TRIAGE ACUITY
____________________________________Signature
PRIMARY ASSESSMENT:
Time:
Nursing history: Triage assessment reviewed

Context: History of : Immunosuppression Recent infection ___________________ Abx:____________________
Recent: URI Sore throat UTI Otitis media Gastroenteritis
None
None
Exposure to known disease (specify):
Chills Rash Crying Irritability Fussiness Decreased activity None
Other history:
Pain Scale
Abuse screening
Nursing exam:
Constitutional: Alert Smiling Playful Ill-appearing Irritable Poorly responsive
Respiratory: R L Bil Generalized Superior Inferior Wheezes Rales Rhonchi
Skin: Turgor: Decreased Rash: Location:
Neurologic: Alert Consolable Tracks Agitated Inconsolable Poorly arousable
Motor function: Sits Walks Decreased tone Flaccid
Other exam:
Evidence of abuse / neglect?

normal
normal
normal
normal for age
Yes
No

Current weight
*Length/Height

Dr/PA/NP notified
:
:
% on: RA O2
:
SaO2
:
:
:
Monitor/Rhythm:
:
EKG
:
Port To Dept
:
X-Ray:
Lab tech
;
;
IV 1 Solution
Location
Location
IV 2 Solution
Urine Dip
:
Nebulizer/MDI
:
Red rails: Up Down
:
Call light
:
Elevate HOB
:
:
:
Ice Elevate
Splint
:
:
:
VA R 20:_______ L 20:_______ B 20:_______
Rate
Rate
*Head circumference
*Birth weight
*Formula
*If less than 1 month gestational age or ED
physician request.
Developmental age appropriate?
Yes
No
____________________________________Signature
Time
RR
BP
O2 Sat
Pain
Rhythm
Status*
Solution, Additive
or Medication
Amount or
Dose
Route
Site
Catheter Pump
size
Rate

BP
NC
I W
NC
NC
NC
NC
NC
* NC:
NC
MEDICATION AND IVS

Time
initiated
INI
I:
W:
Time
No change
Improved
Worsened
OTHER INTERVENTIONS
By
(ini)
Time
DCed
Amount
infused
SAFETY
By
(ini)
Y
Y
Y
Y
N
N
N
N
:
:
:
:
Clinical alarm
Side rails
Call light
Procedural pause
:
:
:
:
:
:
:
:
:
:
:
:
:
:
C-collar applied
Ortho care
Knee immobilizer
Shoe
Crutch education
Wound care
Topical anesthesia
Wound prep
Adhesive
Suturing Staple
Burn care
I and D
Chest tube
:
:
:
:
:
:
:

Aerosol treatment
EKG: ED EKG tech
Intubation
External pacemaker
Central line
:
:
:
:
:
NG: Size _____

Foley: Size _____
Gastric lavage: NG
I and O urine cath
Pelvic exam
:
:
:
:
:
:
:
:

Patient returned
Reassessment
Lumbar puncture
Blood transfusion
Isolation for
N/A
TRAUMA / SURGICAL
Td or specify:
IN
0.5cc
2. Gluteal
3. Anterior thigh
4. Lateral thigh
Oral
cc
Blood
cc
IV
cc
Total
cc
OUT
6. Forearm
7. Hand
8. Foot
9. Neck
10. Intraosseous
Urine
cc
Blood
cc
NG
cc
Total
cc
NURSES NOTES
Time
Ini
CARDIOPULMONARY
GI / PELVIC
Oral
MISCELLANEOUS
Caregiver # 1
Ini
Caregiver # 2
Ini
Crutch training
Wound care
Walker training
Ortho care
Safety issues Foley care
Written
Patient
Verbal
Parent
OTHER
Other
DISPOSITION
Discharged
LWBS
AMA
Expired
Family
Carry
Admitted
Friends
Transferred to: ______________________
Security
Wheelchair
NA
NOTIFICATIONS
Cart
Envelope #___________
Auto
Improved
Ambulance
Worsened
Other ______________________________
MediVan _________________________________
Good
Fair
Poor
Stable
Unstable
Critical
Report called by: _________________________ _____:_____
Report called to: _________________________ _____:_____
D/C ed by: ___________________________ _____:_____
:
:
:
:
:
:
:
Family:
Nursing home:
Pastoral care:
PCP:
Police:
Social services:
Other:
NursingDoc
Customization Options Confidential Information

We recognize that every emergency department functions differently, and we have designed our
templates so that they may be customized to fit your departments unique needs. Below are the
areas in which customizations may be made:
[All areas shown in red on following sample template can be customized to your
specifications]
1. Patient identification area
2. Hospital name
3. Past history, Medications and Allergies
4. Page 1 Right Column (This entire column can be modified according to your needs.
Also, the information for the Adult can be different than that of the Pediatric.)
5. Page 1-- The Primary Assessment Interventions section can be changed to your
specifications.
6. Page 2 -- The Secondary Assessments, Medication and IVs, Patient/Family
Education, and Disposition sections can be modified to your specifications.
7. Page 2 -- Other Interventions column - This entire column can be modified
according to your needs.
8. Other Options
We can design a customized stand alone Orders Sheet for you. Although the
Physician templates already have a section available for Orders, many facilities
desire a stand-alone Orders sheet as well. This Orders sheet can printed on
demand, or each time you print a Physician template (if you are purchasing
physician templates), or each time you print a Nurse template.
Should you have additional requests for customizations, we will may every
attempt to accommodate these requests.

Neuro: CVA Dementia

Heart: MI Angina CHF CAD
Lungs: COPD Asthma
GI: PUD GERD Liver
GU: UTIs Stones
MS: Arthritis
None
Operations: Appendectomy Cholecystectomy PTCA CABG
None
Immunizations: Tetanus: UTD > 5 years Unknown
Other:
SH: Smoke: Current

ETOH: Social
Illicit drugs:
Lives with: Mom
Lives in: Home
CC: CHEST PAIN
Date:
Past Second-hand
Abuse
Alcoholic
Never
None
None
Dad Spouse Family SO

Assisted care Homeless
Time:
Alone
Within 48 hours
Medications:
Allergies:
TRIAGE: T_________
Prehospital:
P_________
Medic unit
RR_________
Vital signs: T
BP ____________
P
RR
O2 Sat _________ % RA O2
BP
O2 Sat
Immobilization
GCS__________
Wt__________ lbs kg
Monitor
Accucheck
Medications
Timing: Onset: ____________ Minutes Hours Days ago
Location: Substernal R L chest
Radiation to: Abdomen Back Neck Jaw R L : Shoulder Arm Hand None
Quality: Sharp Stabbing Squeezing Pressure-like Heavy Crushing Burning Aching
Severity: Mild Moderate Severe or __________/10
Context:
History of: MI Angina Angioplasty Cardiomyopathy Valve disease DVT/PE None
Similar pain in past (diagnosis): ___________________________________________
O2
C-collar
Ice
Splint(s)
Backboard
TRIAGE DISPOSITION
WR
Minor
ED #
TRIAGE ACUITY
____________________________________Signature
PRIMARY ASSESSMENT:
Time:
Nursing history:
Duration: Since onset Intermittent or ____________ Seconds Minutes Hours Days
SOB Palpitations Diaphoresis Abdominal pain N/V Calf pain or swelling Chest rash
Other history:
Nursing exam:
Constitutional: Alert Well-appearing Ill-appearing In distress Poorly responsive
Respiratory: R L Bil Generalized Superior Inferior Breath sounds: Diminished
Skin: Cool Pale Diaphoretic
Neurologic: Oriented to: Time Person Place
Other exam:

partner?
normal
normal
normal
normal
Have you had an unexpected weight gain or
loss over 20 pounds in the last 6 months?
Are you on a special diet?

Dr/PA/NP notified
:
:
SaO2
% on: RA O2
:
:
:
Monitor/Rhythm:
:
:
EKG
:
X-Ray:
Port To Dept
:
Lab tech
;
;
IV 1 Solution
Location
IV 2 Solution
Location
Urine Dip
:
Nebulizer/MDI
:
Red rails: Up Down
:
Call light
:
Elevate HOB
:
:
Ice Elevate
Splint
:
:
:
:
VA R 20:_______ L 20:_______ B 20:_______
Rate
Rate
Nutritional referral given
Do you have trouble taking care of yourself
with feeding, dressing?
Do you fall unexpectedly or frequently?
This column is customizable and will

vary between Peds and Adult
____________________________________Signature
Time
RR
BP
O2 Sat
Pain
Rhythm
Status*
Solution, Additive
or Medication
Amount or
Dose
Route
Site
Catheter Pump
size
Rate

BP
NC
I W
NC
NC
NC
NC
NC
* NC:
NC
MEDICATION AND IVS

Time
initiated
INI
I:
W:
Time
No change
Improved
Worsened
OTHER INTERVENTIONS
By
(ini)
Time
DCed
Amount
infused
SAFETY
By
(ini)
Y
Y
Y
Y
N
N
N
N
:
:
:
:
Clinical alarm
Side rails
Call light
Procedural pause
:
:
:
:
:
:
:
:
:
:
:
:
:
:
C-collar applied
Ortho care
Knee immobilizer
Shoe
Crutch education
Wound care
Topical anesthesia
Wound prep
Adhesive
Suturing Staple
Burn care
I and D
Chest tube
:
:
:
:
:
:
:

Aerosol treatment
EKG: ED EKG tech
Intubation
External pacemaker
Central line
:
:
:
:
:
NG: Size _____

Foley: Size _____
Gastric lavage: NG
I and O urine cath
Pelvic exam
:
:
:
:
:
:
:
:

Patient returned
Reassessment
Lumbar puncture
Blood transfusion
Isolation for
N/A
TRAUMA / SURGICAL
Td or specify:
IN
0.5cc
2. Gluteal
3. Anterior thigh
4. Lateral thigh
Oral
cc
Blood
cc
IV
cc
Total
cc
OUT
6. Forearm
7. Hand
8. Foot
9. Neck
10. Intraosseous
Urine
cc
Blood
cc
NG
cc
Total
cc
NURSES NOTES
Time
Ini
CARDIOPULMONARY
GI / PELVIC
Oral
MISCELLANEOUS
Caregiver # 1
Ini
Caregiver # 2
Ini
Crutch training
Wound care
Walker training
Ortho care
Safety issues
Foley care
di
Discharged
Written
AMA
Carry
OTHER
Other
:
DISPOSITION
Expired
Family
Parent
ll
LWBS
Verbal
Patient
Admitted
Friends
Security
Wheelchair
NA
NOTIFICATIONS
Transferred to: ______________________
Cart
Envelope #___________
Auto
Improved
Ambulance
Worsened
Other ______________________________
MediVan _________________________________
Good
Fair
Poor
Stable
Unstable
Critical
Report called by: _________________________ _____:_____
Report called to: _________________________ _____:_____
D/C ed by: ___________________________ _____:_____
:
:
:
:
:
:
:
Family:
Nursing home:
Pastoral care:
PCP:
Police:
Social services:
Other:

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Page 1: INITIAL Assessments and Interventions

SAINT JOSEPH H0SPITAL

PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia High lipids

Neuro: CVA Dementia

Triage vital signs

Recent hospitalization for: _____________________________________________

More than 120

Emergency Department Nursing Record

Your Hospital Address

Mode of arrival: Walk in Wheelchair Friends Attendant Ambulance Helicopter Police

(including pain scale)

Pvt MD notified: YES

NURSING PLAN: To appropriate area

Breathing treatments ________

EXPECTED OUTCOME: Pain control/Absent

Standing orders or interventions initiated

NURSING DIAGNOSIS: Altered comfort: Pain

Orders, Interventions, and Results

Do you feel safe in your current environment?

Tetanus (see medication section)

Lined out or section completely blank = not assessed

Page 2: ED Course and Interventions

SAINT JOSEPH HOSPITAL

Your Hospital Address

Weight _____________ lb.

MEDICATION AND IV ORDERS

C-collar applied _________________

O2: ______ L NC Mask NRB

NG: Size _____ ________________

Topical anesthesia _______________

Lab draw: ED Lab tech

Emotional support given

Easily record all

Mode of departure: Walking

Condition on D/C: Pain scale: ___________

Verbalizes understanding of discharge instructions

Report called by: _____________________________ _____:_____

Transfer form completed

Barriers to understanding or learning __________________________________

instructions given to:

Report called to: _____________________________ _____:_____

Raising the bar in documentation excellence!

Emergency Department Nursing Record

YOUR HOSPITAL LOGO HERE

PMH: Systemic: HTN DM Cancer HIV Thyroid Anemia High lipids

Neuro: CVA Dementia

NURSE ADULT SAMPLE

SH: Smoke: Current

WE CUSTOMIZE YOUR CHARTS TO MEET

Dad Spouse Family SO

Return visit: Same day

IV: type/amt infused cc

Triage assessment reviewed

Domestic violence screening

Notification per protocol

PRIMARY ASSESSMENT INTERVENTIONS:

NG: Size _ ____________

Report called by: ___________________________ _:___

Report called to: ___________________________ _:___

Referred to: _________________PRN / in days

PMH: Birth weight: _ kg/lb Hospitalizations: _________________None

Report called by: _______________________ _:___

Referred to: _________________PRN / in days

Report called to: _______________________ _:___

D/C ed by: _________________________ _:___