Emergency Department Nursing Rounding Note Template

• ? Identifying information: Include any patient-identifying information, including hospital record number, name, age, and gender.
• ? Chief complaint: This should be similar to the chief complaint section described previously.
• ? Patient behaviors: This will describe the patient’s directly observed behaviors by the nursing staff, including both constructive and negative behaviors. Examples may include “Patient has been calm, cooperative and polite with staff, and adherent with medications,” or something like “Patient has been arguing, threatening to assault staff, and pacing by bedside.”
• ? Medications given: This should be a listing of the medications the nurse has administered to the patient during their shift, including name, dosage, route, and frequency. Also document any noted side effects the patient may complain of, and also any patient refusals to take medication.
• ? Vital signs: While this is self-explanatory, the purpose in a behavioral health context is to ensure and document a period of “stability” for transfer to an inpatient psychiatric facility, if that is what is clinically indicated. This should include listing of common vital signs taken by the nurse during their shift, including temperature, blood pressure, and heart rate. If any aberrant vitals have been noted, those should be documented, with an explanation of what was done to remedy the issue.
• ? Substance use: Include any recent alcohol or other drugs that the patient has ingested. The importance of this is to identify any potential treatment protocols that need to be put in place in order to properly treat any potential withdrawal symptoms. This may include placing the patient on a medication regimen for alcohol or opiate withdrawal. Any information the nurse gathers should be communicated to the ED MD as well in order to ensure that the treatment team can develop an adequate care plan. The nurse will typically have more direct patient interaction compared with the ED physician, and may have developed a different level of relationship, and therefore be privier to more detailed historical background information that the ED MD should be aware of.
• ? Activities of daily living: This section should include a description of the patient’s overall ability to carry out daily tasks such as toileting, showering, and feeding themselves. Also included will be any special care need issues such as assistance with toileting or feeding. This is important because these issues can affect these patient’s ability to be transferred to a locked psychiatric inpatient hospital setting, and may steer the team in the direction of seeking out a medical-psychiatric inpatient hospital bed.

• ? Ambulation: This should include a brief description of the patient’s ambulatory status—essentially, can they walk on their own, or do they need some type of physical or structural assistance to do so. In this section, any use of walkers, canes, wheelchairs, or prosthetic devices should be noted.
• ? Restraints: State any episodes of physical or chemical restraints the patient medically required during the nurse’s shift. A clear rationale for the need for these restraints should also be documented in this section. Also document the name of the MD that placed the order, and the follow-up care that was implemented once the restraint was placed, and after it was discontinued.
• ? Legal status: This is simply a description of the patient’s legal status. Examples are “voluntary” or “on a legal psychiatric hold,” which will vary depending on the state where the patient receives treatment. Any changes in legal status that occur during the nurse’s shift should also be noted here. For example, if the patient was taken off a psychiatric hold and was placed on voluntary status, this should be documented.
• ? Visitors: This section should include a list of any and all parties that have come to visit with the patient during the nurse’s shift. The nurse should also include any potential problematic interactions between visitors and staff or the patient. Any restricted visitors or visitors that can be a potential support for the patient upon discharge from the ED should be noted in this section.