Reading Emergency Department Records Like a Nurse
Emergency Department (ED) records are dense, fast-paced, and often difficult to interpret without clinical experience. Yet, the ED is where many lawsuits begin—delays in care, failures to escalate, missed opportunities, and communication breakdowns frequently originate here.
Attorneys often ask: “How do nurses interpret ED records so quickly?”
Below is the structured mental framework nurses use to extract clarity from chaos—and how you can apply it during case screening, merit review, and liability analysis.
1. Start With Triage: The First 10 Minutes Tell You Everything
Triage establishes the trajectory of care. Errors here often ripple throughout the entire encounter.
Questions attorneys should ask:
- Was the patient appropriately triaged?
- Were abnormal vital signs repeated promptly?
- Did the triage level match severity?
- Was pain assessed and reassessed?
Red flags:
- Long delays with concerning symptoms
- No repeat vitals for 30+ minutes
- Conflicting documentation (e.g., “resting comfortably” with O₂ sat 88%)
2. Build a Timeline of Orders, Interventions, and Responses
In the ED, time is everything. Nurses instinctively track cause-and-effect.
- 13:10 – Shortness of breath documented
- 13:12 – O₂ saturation 88%
- 13:26 – Provider notified
- 13:37 – Intervention performed
3. Compare Care to Expected Standards—Not Outcomes
Nurses evaluate care based on what was known at the time, not hindsight.
- Repeat abnormal vitals
- Escalate deterioration
- Reassess after interventions
- Document communication
4. Communication Failures: The Most Common Liability Trigger
- No timestamped notification
- “MD aware” with no detail
- No documented escalation
If communication isn’t documented, legally it may not be considered to have occurred.
5. Identify Missed Opportunities and Causation
- Delayed medications
- Failure to monitor after high-risk meds
- Missed sepsis, stroke, or MI indicators
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