Emergency Department Record

Identify and list the top 10 most important documents within the electronic health record. Discuss the importance of each document for clinical documentation improvement purposes. Select any 10 from the listed documents below for your discussion:

1. Discharge Summary
2. Emergency Department Record
3. Glasgow Coma Scale
4. Vital Signs Flowsheet
5. Problem List
6. History and Physical
7. Progress Notes
8. Consultation Reports
9. Diagnostic Test Results
10. Physician Orders
11. Anesthesiology Record
12. Operative Reports
13. Medication Administration Record
14. Ventilator Flowsheet
15. Wound Care Notes

Sample Solution