SoapLab - Clinical Documentation Training

Emergency Documentation Principles

Emergency documentation must be fast, accurate, and legally defensible. In high-acuity situations, your notes may be scrutinized in malpractice cases, quality reviews, and mortality conferences. Document in real-time when possible, and always prioritize patient care over documentation.

Triage Documentation

Triage documentation sets the stage for the entire encounter: **Essential elements:** • Chief complaint in patient's words • Vital signs with time • Acuity level (ESI 1-5 or your system's scale) • Brief relevant history • Allergies • Initial interventions (if any) • Rationale for acuity assignment

ESI Triage Levels

Emergency Severity Index documentation:

•ESI 1: Immediate life-saving intervention needed (cardiac arrest, respiratory failure)
•ESI 2: High risk, confused/lethargic, or severe pain (chest pain, stroke symptoms)
•ESI 3: Stable but needs multiple resources (labs, imaging, IV meds)
•ESI 4: Stable, needs one resource (X-ray OR labs OR simple procedure)
•ESI 5: Stable, needs no resources (prescription refill, simple wound check)

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Time-Stamping Critical Events

In emergencies, document times precisely: • Patient arrival time • Triage time • Provider evaluation time • Critical intervention times (intubation, medications, procedures) • Consultant notification and arrival times • Disposition decision time • Actual departure time Example: "1423 — Chest pain onset per patient. 1445 — EMS arrival. 1448 — ED arrival. 1450 — ECG obtained showing STEMI. 1452 — Cardiology notified. 1455 — Cath lab activated."

Resuscitation Documentation

Code documentation requires specific elements: • Time code called • Initial rhythm • CPR quality metrics (if available) • Medications given with times and doses • Defibrillation attempts with joules and response • Airway management (attempts, success, confirmation method) • IV/IO access • Rhythm checks and changes • ROSC time (if achieved) • Time of death (if applicable) • Family notification • Who was present

📋 Code Documentation Example

**Code Blue — 1532**
• 1532: Unresponsive, pulseless, apneic. Code blue called.
• 1532: CPR initiated, monitor shows VFib
• 1533: Defibrillation 200J biphasic — VFib continues
• 1535: Epinephrine 1mg IV push
• 1536: Defibrillation 200J — converted to PEA
• 1538: Epinephrine 1mg IV push
• 1540: Intubated by Dr. Smith, ETCO2 confirms placement
• 1542: Rhythm check — sinus tachycardia with pulse
• 1542: ROSC achieved
• 1545: Post-arrest care initiated, targeted temp management discussed
• Family notified at 1550 by Dr. Smith

Trauma Documentation

Trauma-specific documentation elements:

•Mechanism of injury (detailed)
•Prehospital interventions and response
•Primary survey findings (ABCDE)
•Secondary survey (head-to-toe)
•GCS score with components (E_V_M_)
•All imaging results
•Procedures performed with times
•Consultant involvement
•Disposition and transport

Medical Decision Making (MDM)

Document your clinical reasoning, especially for: • Why you ordered specific tests • Why you ruled out serious diagnoses • Why the patient is safe for discharge • What instructions were given • What follow-up is planned • What return precautions were discussed This protects you legally and demonstrates quality care.

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Against Medical Advice (AMA)

AMA documentation must include: • Patient has capacity to make decision • Risks of leaving explained (be specific: "You could die") • Patient verbalized understanding of risks • Alternatives offered • Patient's stated reason for leaving • Offer to return if changes mind • Prescriptions/instructions provided despite AMA • Patient signature (if possible) • Witness signature

Discharge Documentation

Complete discharge documentation includes:

•Final diagnosis
•Condition at discharge (stable, improved, etc.)
•Medications prescribed (with instructions)
•Activity restrictions
•Follow-up appointments
•Return precautions (specific symptoms to watch for)
•Patient education provided
•Patient verbalized understanding

Emergency & Urgent Care Documentation

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