Get the free Emergency Department Patient Record Form PDF - 208 KB - cdc

Form Approved OMB No. 0920-0278 Exp. Date 08/31/2009 CDC 64.136 NHAMCS-100(ED) U.S. DEPARTMENT OF COMMERCE FORM (10-2-2007) PATIENT RECORD NO.: Economics and Statistics Administration U.S. CENSUS

How to fill out emergency department patient record

How to fill out emergency department patient record?

1. Begin by gathering all necessary patient information, such as the patient's name, contact details, and medical history.
2. Record the reason for the patient's visit to the emergency department and any symptoms or complaints they may have.
3. Document the vital signs of the patient, including their temperature, blood pressure, heart rate, and respiratory rate.
4. Note any medications the patient is currently taking or has taken recently, including the dosage and frequency.
5. Record any allergies or adverse reactions the patient has experienced, especially to medications or medical treatments.
6. Document the physical examination findings, including any abnormalities or injuries observed.
7. Include the results of any diagnostic tests or imaging studies performed, such as blood tests, X-rays, or CT scans.
8. Record any procedures or treatments administered to the patient, along with the date, time, and person responsible.
9. Note any consultations or referrals made to other healthcare providers, specifying the reason for the consultation.
10. Finally, sign, date, and authenticate the patient record to ensure its accuracy and validity.

Who needs emergency department patient record?

1. Emergency department healthcare providers, including doctors, nurses, and other medical staff, require access to patient records to provide appropriate and timely care.
2. Hospital administration and quality assurance teams may need patient records for auditing, tracking outcomes, and ensuring compliance with healthcare regulations.
3. Patients themselves may also request a copy of their emergency department patient record for personal records or when seeking care from other healthcare providers.

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What is emergency department patient record?

Emergency department patient record is a documentation of the medical information of a patient who has received treatment in the emergency department of a healthcare facility.

Who is required to file emergency department patient record?

The healthcare facility and its staff, including doctors, nurses, and administrators, are typically responsible for filing the emergency department patient record.

How to fill out emergency department patient record?

The emergency department patient record is usually filled out by the healthcare professionals involved in the patient's care. It includes details about the patient's medical history, symptoms, examination findings, treatment provided, and any follow-up instructions.

What is the purpose of emergency department patient record?

The purpose of an emergency department patient record is to document the patient's medical information, which can be used for future reference, continuity of care, research, quality improvement, and billing purposes.

What information must be reported on emergency department patient record?

The emergency department patient record should include the patient's demographic information, chief complaint, past medical history, allergies, vital signs, physical examination findings, diagnostic tests performed, medications administered, procedures carried out, consultations requested, and the outcome of the visit.