Charts/ Documentation

While in the ED, it is imperative to learn the importance of good documentation.  Writing a well constructed chart will help you with your thought process as you work through a differential diagnosis based on a chief complaint, why/how you ordered specific tests, your interpretation, and ultimately the patient’s disposition.

In order to help you practice this, you can use the below document as a guide.  Feel free to download and print out for guidance during shifts.  Try to fill out the historical features, physical examination and differential before presenting to your senior resident or attending.

By the end of your rotation, you will be expected to turn in THREE “charts” for review.  
Important Chief Complaints to consider for documentation Include, but are not limited to:
  • Headache
  • Altered Mental Status
  • Chest Pain
  • Shortness of Breath
  • Fever
  • Female Abdominal Pain
  • Male Abdominal Pain
  • Overdose/Psychiatric Complaint
  • Trauma
  • Back Pain
  • Endocrine related complaint ( DKA, HHNK, Thyrotoxicosis, etc)
  • Pregnancy Related Complaint.

MSIV Clinical Documentation Sheet