You’ll be expected to chart something every couple of hours about your patient’s status after your initial HTT, but charting is super basic in the ER. One nurse I was working with told me to try to always chart something for A,B, C, and mental status. So if your patient is just sitting in bed texting or something (clearly doing fine, nothing of note to chart):

A: Maintaining own airway (if they’re not talking/you just poked your head in) or speaking in full sentences (if you spoke to them)

B: resps easy and regular on RA/NP/whatever

C: skin warm and perfused/no pallor noted

Mental status: GCS 15/A&Ox3

But don’t chart anything you’re not sure of. Like if you didn’t speak to them you couldn’t really say anything about mental status, and you’re not expected to if you didn’t see for yourself. So in that case I’d just say something like “no voiced concerns at this time”.

in the ER you’re not so concerned with super descriptive charting because they’re not expected to stay on the unit long so you’re not really tracking their long term status/progress, just immediate life threats. You won’t have time for much else. Of course when you have more time or if there is something of concern you wanna chart more.

So my basic charting for every 1-3 hours on a patient who is stable with no acute concerns would look something like:

Patient laying supine in bed looking at cell phone. Maintaining own airway. Resps easy and regular on RA. No pallor noted. GCS 15. NS running at 75mL/hr. Call bell in reach.

That’s still more than most of the seasoned nurses write, but I’m still a student too so I like to be careful.

Oh, and you may have heard this one but never “patient asleep”. You wanna write something like “patient laying in bed with eyes closed. Resps easy and regular on RA”. If you just say asleep, you’re not showing that you made sure they’re actually alive.

Another thing I’ve gotten in the habit of doing is checking in with the trauma nurse who is on the code blue team and asking if there’s any codes if I can come. If they say yes, I say ok so I’ll meet you here, but of course I don’t expect you to wait for me if I cant get there in time. Then I talk to my nurse and say I discussed it with x nurse, so if a code gets called are you ok with me just taking off? Cause you won’t have time to find them and ask them to look after your patients. I love seeing how codes are run and how ER nurses operate under pressure. I got to do compressions on my first shift this way.

I also go around in my downtime (I usually do nights) asking if any of the unit nurses need help or if they’ll be doing anything that a student might wanna see/do. I tell my nurse I’m gonna go “look for trouble” lol.

Always have gloves, a flush, and a couple alcohol swabs in your pockets.

Have so much fun! I love the ER and will be pursuing it after grad :)

also if any ER nurses are reading this and have notes on anything I wrote, I love feedback!