As a student nurse, you must learn to transcribe an array of emergency room reports. There are dozens, from doctors' reports, to lab reports, to X-ray reports and reports from emergency personnel when a patient comes in by ambulance. Not all hospitals use the same types of reports.
Instructions
1. Find out which doctor is caring for the patient. To transcribe an emergency room report requires you to be able to read the doctor's handwriting. A doctor's handwriting is often illegible. Each doctor has his own protocol for certain conditions. Identifying the doctor makes it easier to interpret the orders she gives.
2. Notice the description of the reason for the emergency room visit. Forms are limited in the space they provide. As you transcribe an emergency room report, be sure to write down specific details about the incident, including time and date of onset of illness, symptoms or accident description. Use the notes on the report, but add details in your own words.
3. Ask if all the patient's concerns are addressed. Ask yourself which problems need immediate attention. Find out if the patient requires medications and what route (IV, mouth, injection or suppository) is needed. Check to see which problems need to be referred out for further treatment by specialists.
4. Make sure when you transcribe an emergency room report that you cover every aspect of the illness or injury, including specific details about the nature and appearance of injuries such as cuts, bruises and broken bones. Note the location on the body of such injuries. This information will be especially important if the emergency room report ever has to be used as a legal document, subject to subpoena.
Tags: emergency room report, emergency room, emergency room, room report, transcribe emergency room, details about, doctor handwriting
