ABSTRACT
Record keeping in the emergency department is very important. The usually high patient load and acuteness of presentation generally require a brief format that is easy to read and easy to complete. Check off and short answer sections facilitate timely completion. Documentation is not only helpful for the team members to convey what each has done but also provides continuity of care when the information is copied for the receiving treatment providers. Its inclusiveness can make a difference during reimbursement negotiations with third party payers and can be used as evidence in a malpractice suit. Records can become a meaningful tool for training students in the field in what to look for and how to report it.
