Vitals

• Multiple sets when needed

• Take only palp. Pressures without at least one baseline, full pressure

• Take only partial set of vitals

Medications

• List all meds taken by patient

• Leave spot on report blank

• Use "see list" without attaching a copy of the actual list

Allergies

• List all allergies including non-med allergies

• If patient has allergies list side effect and sensitivities etc.

• Leave spot on report blank

• Use "see list" without attaching a copy of the actual list

PMH

• List all medical history even if it does not appear to be relevant to the current event

• Leave spot blank on report

• Use abbreviations unless they are commonly accepted and known by all healthcare providers

• Leave out some items that you do not think are relevant to the current problem

Times Recorded in Flow Chart

• List times for each set of vitals, med administration, skill or procedure performed

• Leave times missing or only enter some times

Name of Medical Control Physician

• Give name of physician spoken to for on-line medical direction or put "Standing Orders" for off-line medical direction

• Leave spot on report blank

• Use terms such as "ER doctor"

Stroke Protocol

• Document a thorough neuro exam

• Perform the Boston Stroke Scale

• Document that the entry note nurse was advised that this patient warranted activation of the stroke team upon arrival to ED.

• Forget to activate the stroke team

12 Lead EKG

• Perform a 12 lead on any patient suspected of having a cardiac event

• Attach all 2 lead and 12 lead strips to run report and QA copy of run report.

• Perform on diabetics with vague complaints

• Label with patient name, date etc.

• Forget to attach a copy of strips and 12 leads to QA copy of run report as well as copy left at facility

• Write 12 lead performed without attaching a copy

DNR

• Document contact with medical control for all DNR patients who are not treated to protocol

• Attach copy of DNR order to both run report and QA copy of run report

• Forget to attach copy of DNR to run report and QA copy of run report

Blood Glucose

• A B.S. on all altered mental status patients or diabetics who exhibit other complaints that could mask a hypoglycemic episode

• Document B.S. clearly on run report

• Remember to provide a before and after B.S. for suspected hypoglycemic patients

• Forget to document B.S