This is Steve Carroll, and you're listening to the Em Basic podcast. Today's episode is all about

documentation in the ED. This is not traditionally thought of as core content, but I've had a lot of

requests to discuss this topic. Documentation is something that we do with every patient, so it's

important that we get it right. Good documentation is key towards protecting yourself

and the patient. In this episode, we'll talk about how to document efficiently and effectively

in the EAD and some tricks to the trade. As always, this podcast doesn't represent the views of

Parenthood Department of Fence, US Army, the Fort Hood Post Command. Before we go any further,

I want to talk about my views on documentation.

If you ask 10 EM docs how they document, you'll get 12 different answers.

There is no one right way to document your patient encounter.

These are just my views on the subject.

Whenever we talk about documentation, it always seems to be framed in the context of,

this is what you need to do so you

don't get sued. Others will say that what you write down won't matter one bit. If there is some

bad outcome, the plaintiff's attorney will take your chart, blow it up to a hundred point type,

and take everything out of context. I fall somewhere in the middle on this. I don't think that there's such thing as bold-proof

documentation, but I also believe that good documentation may save you a lot of time and headaches

later. Good documentation can be the difference between just doing a deposition instead of going

to trial, or maybe even not having to do that deposition in the first place. More importantly, good documentation is good for your patients

because it can help you and anyone else treating them down the road,

know what was done, and know what you were thinking.

So let's talk about how to approach documentation from the beginning.

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