Medical Documentation - Kids Health WA (PMH ED Guidelines)

Policy

Policy or procedure

Documentation

Minimum expectations of medical documentation include the following:

Accurate, legible, contemporaneous and complete
The importance lies in patient care, communication and potential medico‐legal issues
All ED notes should have a patient label, medical doctor’s name and designation, date and time, signature, clinical diagnosis and plan

Notes are audited regularly in our Emergency Department.
Instead of hand writing notes, you can type your notes using the following templates:

In trauma and resuscitation cases it can be difficult to maintain documentation when patient care is a priority. This should be done in a contemporaneous manner, and updated regularly as more information or findings arise. Completion of the full documentation should be done at the earliest possible opportunity. As it is in these cases that patient history, communication and medico‐legal issues can become paramount.

Documentation In A Resuscitation

In PMH Emergency Department, use the Emergency Resuscitation Form for documentation (MR301.05 - with an orange border, located in the Resuscitation Bay)
It is essential to place a patient sticker on the front and back of the form
Write clearly your name and designation at the top, and sign the bottom, and document all staff present at the resuscitation
Further notes can be made on the ED Medical Progress Notes Template or Clinical Progress Notes if required
Discussions with medical specialities should be documented, timed, dated and signed, and contain the name and title of the Speciality Doctor

Documentation In A Trauma

In PMH Emergency Department, use the ED Major Trauma Form (MR301.04 - an A3 folded sheet located in the Resuscitation Bay)

Communication and paperwork

ED Medical Assessment Template
ED Medical Progress Notes Template

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