Essay: The Need for Good Documentation

Sample Essay

Words 2,320

The primary professional responsibility of an Emergency Medical Services nurse is patient care. When an EMS nurse is called on to help a person inflicted with disease or a trauma victim, the initial observations of the nurse are very important in later diagnosis and treatment of the patient  (National Association of EMS Physicians, 2002).

It is of essential importance that the EMS nurse write down the manner in which the patient was found, a description of the present injury or illness and how the patient or witnesses say it happened. If the patient or one of their family or friends or a witness at the scene of the accident makes an observation about the state of the victim that seems like it might come in use in later diagnosis, it is important that it be written down in quotation marks. Something that might sound like a frivolous comment at first might provide important clues for the diagnosis of the patient’s condition. Any complaints the patient makes should be written down as well. If the patient refuses any specific type of treatment or medication or method of transport, it should be noted along with their reasons for the refusal. It is important that a detailed physical examination of the patient is done and the results are noted down. The nurses should note down in specific terms what they saw, felt and smelt during the exam, noting the sites of pain and muscle tenderness etc. The report should include the vital signs of the patient; breathing, pulse, blood pressure and body temperature and the vital signs should be taken several times over short  intervals of time  (National Association of EMS Physicians, 2002) .

Mental status of the patient, any reported complaints and allergies and past medical history, current treatment and other relevant information that may be important for patient care should be noted for the benefit of the emergency department physician and the attending physician of the patient. The physicians that continue the care of the patient will be interested in knowing what medications and treatment their patient has received. If the patient had a bad reaction to a specific medication, the later physicians should be able to find it out from prior documentation, instead of putting the patient through the same ordeal over and over again  (Brennan & Krohmer, 2005).

Kindly order term papers, essays, research papers, dissertations, thesis, book reports from the order page.