Nurse performs and documents initial assessments
Pt. readmitted to ER comatose the next day pt taken directly to trauma bay.
Nurse transfers care to Patient's assigned nurse RN
Jones MD assesses pt and orders CBC and CMP
RN performs assessment and need for medical records from the assisted living facility along with family members information.
Dr. Jones assesses the pt. and orders new tests to include PT INR, CT, and digitalis level
Nurse documents incomplete PMH and family information/phone number due to pt. being poor historian.
List of medications and PMH retrieved from EHR from last visit
Nurse transfers care to MD/Provider
Dr. Jones has an inaccurate list of medications/PMH diagnoses pt with a slight tender-to-touch hematoma.
Dr. Jones orders to discharge the patient home rest, continue current medications and f/u PCP tomorrow
75 y/o male pt arrives to the ER with CC ground level fall with closed head injury
Pt PMH reveals diagnosis of A-fib and additional medications digoxin and coumadin
Test reveals subdural hematoma, digitalis level is toxic and INR 8.0.
Dr. Jones feels angry because of lack of info. He demands to speak to COO to make sure Er takes measures to correct poor workflow and task management.