DEPARTMENTAL POLICY AND PROCEDURE

Policy Title Policy No. DPP-ER-02

Version No. 1
Emergency Room Nurses Practice
Page No. Page 1 of 3
Issue Date: Effective Date: Review Date:
15-6-2023 30-6-2023 30-6-2026

1. PURPOSE:

1.1 To establish uniform guidelines in the nursing process and documentation by the ER
Registered Nurses (RNs).

2. APPLICABILITY:

2.1 ER Nursing Staff.

3. REPONSIBILITIES:

3.1 This policy and procedure describes the standardized process of emergency room(ER) nursing
methods for Al Rai Medical Complex patient care nursing practices in the ER.

4. DEFINITION:

4.1 Emergency Room (ER) Nurses Practice - It is the process of receiving, assessing, managing
the ER patients, and documenting in the electronic ER documentation.

5. POLICY:

5.1. To provide quality assessment and continuity of care.

5.2. To protect the nurse in medico-legal situations;
5.3. All assessments rendered to patients are documented accordingly;
5.4. Assessment, planning, intervention, and reassessment will be documented from presentation
to ER till discharge or transfer to another facility.

6. PROCEDURE:

6.1. Upon arrival of patient:

6.1.1. The triage Registered Nurse (RN) will receive the patient, after that he/she or a fam-
ily member or a friend has opened a file in the ER reception, do an initial assessment
to triage the patient (according to PPG Triage of Patients) and to initiate an immedi-
ate treatment when required;
6.1.2. The triage RN will document the Triage data in the E.R Electronic Documentation
record.
 DEPARTMENTAL POLICY AND PROCEDURE

Policy Title Policy No. DPP-ER-02

Version No. 1
Emergency Room Nurses Practice
Page No. Page 2 of 3
Issue Date: Effective Date: Review Date:
15-6-2023 30-6-2023 30-6-2026

6.1.3. The triage RN will endorse the patient condition to another E.R- RN & guide the pa-
tient to the treatment room or to ER reception area to wait according to the acuity
level of the patient and the treatment room occupancy status;
6.1.4. The triage RN will receive all patients coming to the clinic and guide them accord-
ing to their acuity level.
6.2. Further Assessment and Management (all information will be documented in the electronic
ER Nursing documentation Record):
6.2.1. Previous medical history and assessment will be done and documented in their re-
spective areas;
6.2.2. Pain assessments, treatment provision as per the physician’s order, and reassessment
after 30-45 minutes of an intervention provided, all will be done and documented in
electronic documentation.
6.2.3. Reassessment of the systems focusing on the Chief Complaint will be performed ev-
ery 30-60 minutes and/or after any change in the patient’s condition, which will be
documented in a concise & complete way in the Reassessment Chart;
6.2.4. All treatment procedures will be done according to the physician order, and they will
be documented in their respective area;
6.2.5. All diagnostic procedures will be ordered by the physician, and the receipts will be
issued from receptionist to the patient companions which will be sent with the pa-
tient by the transferring staff to the designated diagnostic department such as X-Ray
department. These diagnostic procedures will be documented in their respective
area;
6.2.6. The Laboratory (Lab.) Works will be ordered by the physician, in the system and the
receipts issued from the ER receptionist and will be sent with the samples to the lab-
oratory.
6.2.7. All medications ordered by the physician will be g documented in the Electronic
nursing documentation sheet .Chart specifying the name, the dose, the route of ad-
ministration, the site of administration (If IM, SC), the amount and type of intra-
venous fluid used & the duration of administration (If ordered as IV infusion);
6.2.8. The last decision about the patient’s condition or disposition will be documented in
the respective area; if the patient is discharged or transferred to another facility with
the physician name. The patients/family education about the disease process, will be
given by the physician.
6.2.9. The patient safety measures during transfer from the ER will be decided by the RN/
physician taking care according to the patient condition, who will be transferred by
stretcher with side rails up while transferring to x-ray ,ultrasound or to transfer an-
other facility by ambulance stretcher that will be documented
6.2.10. The equipment’s used during the transfer of the patient and the staff transferring will
be handled according to the patient condition, and will be documented in the respec-
tive area.
 DEPARTMENTAL POLICY AND PROCEDURE

Policy Title Policy No. DPP-ER-02

Version No. 1
Emergency Room Nurses Practice
Page No. Page 3 of 3
Issue Date: Effective Date: Review Date:
15-6-2023 30-6-2023 30-6-2026

6.2.11. A final brief evaluation of the patient condition and the vital signs along with the
date and time will be taken and documented prior to the discharge/transfer
6.2.12. Once a patient will be decided for discharge or transfer, the receptionist will settle
down all the financial clearance of the patient with the patient or with any of his/her
companions.
6.2.13. The patient’s valuables will be handled according to the Policy.

7. ATTACHMENT:

7.1 DPP-ER-02-A 01: Electronic E.R Nursing Record

8. REFERENCE:

8.1 None.

9. APPROVALS:

Prepared by Title Name Signature Date

Head Nurse
Reviewed by Title Signature Date
Quality Improvement
Coordinator
Chief Nursing Officer

Chief Medical Officer

Approved by Title Signature Date
Chief Executive Officer