Print

Print


MabelWe use the "T" system and I find it to be lacking in certain pediatric
areas. For those who are not familiar with these: a set of ready to complete
checklist/write in sheets based on presenting symptom. There are the general
illness, injuries, cough, V/D, etc. Yet, there is no sheet for sickle cell
disease or chest pain. The list of discharge diagnosis is not always
complete. For instance the "Upper Extremity Injury Template" does not list
radial head subluxation as a possible diagnosis,  the "Wheezing Template"
does not offer fever as a diagnosis, and the "Facial/Head Injury" offers
contusion/hematoma/concussion but not just plain old head trauma. These
sheets do not have an area to list an age or the vitals signs - things that
we commonly write in on the sheet. Some of the areas that you are supposed
to write in for either the hx or progress in the ED are very limited. The hx
area for head trauma allows you to write maybe a sentence. It is difficult
to document if meds were given or the course of ORT or asthma tx. There is a
very small area for the attending progress note so most of us
(attendings/PNP) use the template and the residents write progress notes.
Also, there is no area to document discharge instructions or medications.
Some nice aspects of them are the laceration repair procedure note, LP
procedure, and documentation area that the PMD was notified. They can be
quick but sometimes finding the right word to backslash or circle is not. I
find that the concept is a good one but I think that the flow of the hx can
be awkward and there needs to be improved documentation areas. (I think that
I tend to lean heavily on the problem with documentation b/c there are so
many times that I am called by a PMD wanting to know what happened in the ED
and I pick up the T sheet and I am not seeing a lot on it.)