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