PubMed · 11096924
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D Glover. Keep your record clean.. https://pubmed.ncbi.nlm.nih.gov/11096924/
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The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal statute that should be recognized and understood by all nurses who work in an emergency department or other settings where patients with potential emergencies may present themselves for care. It is a law that imposes specific legal requirements on hospitals in terms of medical screening, stabilization, and transfer of patients, regardless of whether they are outpatients or inpatients. As agents of the hospital, nurses are responsible for maintaining compliance with EMTALA regulations. This article reviews the components of EMTALA and the ways in which they are applied to clinical nursing practice.
At the conclusion of its mission, every nuclear facility eventually undergoes decommissioning. An early and essential part of decommissioning is the conduct of an extensive site characterization process. A Historical Site Assessment (HSA), a critical aspect of the site characterization process, sufficiently informs the facility owner and stakeholders of the radiological contaminants on the facility site. This allows for a safe and optimal decommissioning process. Although many nuclear facilities in the United States are permanently closed, many are entering a long-term storage condition typically known as safe storage (SAFSTOR). In these cases, only minimal characterization may be conducted initially. Full characterization may not occur for several decades. Additional delays in decommissioning will occur in operating facilities that successfully extend their operating licenses. In both of these cases, the conduct of a robust HSA can provide a valuable and cost-beneficial decommissioning step. This paper suggests that a substantial portion of the early site characterization process should be conducted prior to the conclusion of a facility's mission.
AIM: To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department. METHODS: All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items RESULTS: After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards. CONCLUSION: A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.