How Are Emergency Room Notes Made?

By Alana Olson

Have you heard about emergency room notes? You may not have known of this note until you have searched and read this article. The notes coming from the emergency room are actually very important documents and those that handle them must be thanked for having the proper training on such important documentation.

The pre-med students who are looking forward to working in the ER may not even have a clear view on what goes on the emergency room note developments and procedures. The emergency room notes involve all the happening and procedures that are important to be documented by the medical practitioners attending to the needs of the patients rushed in the emergency room.

A scribe in the ER is the one who handles the documentation of the ER notes. Any person assigned to the job is to follow all the doctors’ procedures as well as organize them for the emergency records in the room to be handled faster. The scribes making the emergency room notes are almost the same or synonymous in the responsibility as to a secretary of a doctor. The necessary forms that need to be completed by the patients are handled as well as the exam procedure, present illness and its history and above all, the findings of the physicians in the step-by-step procedures done on every individual who steps into the emergency room for treatment. The scribes are like the shadows of the busy doctors in the ER since this place is always bustling with activities, they play an important role in getting the necessary information that they find essential.

The admission or discharge of a patient in the hospital from the ER is a part of the ER notes. The ones that provide some training for the scribe that will be handling the full documentation within the ER are the physicians’ assistants. Usually, pre-med students get into these kinds of jobs and provide them with the invaluable experience they need. The doctor’s every move needs to be observed and follow the health provider from patient to results of x-rays and other laboratories. Diagnosis, suturing and broken bone splinting are among the things seen in the emergency room and must be reflected in the emergency room notes of the scribe.

The people who work in completing these ER notes can experience a lot of hard work even when they have the minimal training on the exact procedure. The challenge in the work is the development of the accurate patient experiences without any errors. Terminology is another issue that needs to be developed for the medical record needs in the job of the ER scribe.

These ER notes play very important roles in the medical records that may be needed for criminal, accidental and medical procedures for the patients’ needs of documents.

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