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Electronic Medical Records (EMR) Documentation

This document is a summarised version of the EMR Quick Reference Guides available via the WH Intranet. The summary has been created to combine best practice information into one document specific to the Emergency Department, and has been endorsed by the ED Leadership Team . Staff should review the EMR Reference Guides if they require further information.

Overview

This QRG provides nursing staff with the relevant information about EMR documentation. Involving the inserting of all patient’s information including pathology results, vital signs, & lines & devices.

Using EMR has made patient information easily accessible across all sites for all healthcare workers among Western Health. It is therefore important for each staff member to continuously update their patient’s information on to the system so that others involved in the patients care are able to deliver a high standard of care.

Applicability

This QRG applies to all presentations to the Emergency Department.

Responsibility

It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG, that it is implemented according to the guidelines as outlined within, and that there is compliance by all staff members.

Guideline Details

  • Recording alerts & allergies, lines & devices (Not in an emergency).
  • Correctly filling out the MAR & ensuring all medications are signed & charted correctly.
  • Filling out the fluid balance chart by documenting all Intravenous fluids & drugs given.
  • Patient risk assessments such as falls, pressure injuries, daily Covid screen.
  • Nurse initiated orders & pathology requests. Please ensure to look under what medications & pathology is approved for nurses within the department to order.
  • Access all medical notes & results (able to see previous admissions).
  • Medical staff Complete ED interim orders as required (see EMR QRG here)
  • Complete COVID-19 EMR initial Screening Tool (see EMR QRG here)

Important EMR Documentation Messages

IV Cannula Insertion:

Figure 1: Documenting IV cannula insertion on EMR

 

Important: staff should never selected ‘Inserted Under Emergency’ unless the patient is in an arrest situation.

Medication Administration:

Figure 2: Documenting in the Medication Administration Record (MAR)

 

Important: if medications not given always document why in Medication Administration Record (MAR)

Key EMR Documentation Short Cuts:

   
 In menu:

  • Patient Information – to check patient details
  • MAR – to check medication chart
  • Observation Chart – to document vital signs prior to transfer
  • Interactive View & Fluid Balance – document patient risks and fluid balance.
  • Activities and interventions – check pathology results.
  • Continuous notes – review all admission notes
  • Allergies/Sensitivities – add and review allergies

Supporting Documents

Staff are able to access all relevant EMR quick reference guides found on the intranet.

https://liveemr.wh.org.au/quick-reference-guides/

Document Governance

Title: Electronic Medical Records (EMR) Documentation
Version: 1.0
Date Published: February, 2021
Date of scheduled review: 01/02/2022
Author: Approver:
ED Leadership Team ED Leadership Team

 

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