Nursing Documentation - Body Systems

  1. Hi!
    Im a bit confused at the moment (well, more so than usual) :spin: . Whenever i go to write my nursing notes, i freeze and forget everything . I usually remember, but i want to cut down on the nervousness and the length of time it takes me to write notes.

    Can anyone help me out with nursing notes based on the body systems ie: CNS, CVS, Renal, GIT, Metabolic, Skin integ, Social....
    I have the list of the systems, but where i used to work had a double sided A4 sheet which listed each thing that went under each heading. Ive been searching the net for ages and cant find anything like it.

    Can someone PLEASE direct me to a link, or something to help me out?

    Thanks stacks in advance for anyone so kind to help!!!
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  2. 7 Comments

  3. by   Katnip
    I just made up my own cheat sheets to help me remember the details. Just List the systems from head down, then add things to prompt you like meds, dressing changes, etc.
  4. by   AdelaideChic
    Thanks cyberkat, ive sorta been jotting things down as I go, but i might try to compile it now!

    Any other hints or advice?

    Im considering asking someone from my old workplace to try and photocopy that sheet for me, but people werent too happy when i left (I left cos i graduated my RN and i didnt accept the program that my previous workplace offered me, i went somewhere bigger, i dont think they were too happy...)

    Thanks
  5. by   drpsrn
    When I was a new nurse on a trauma acute care floor, I found it was much easier if I charted the second I stepped out of the room. It only took a few minutes and I could remember right then. I could easily move on to my next patient and didn't have to recall everything about 5-6 patients after I had seen all of them. This also made my charting throughout the day easier and quicker. Good luck.
  6. by   cardiodiot
    Easiest way for me:
    HEENT: head, eyes, ears, nose, throat
    Chest: cardiac & resp
    GI: yep
    Extremities: you can include trunk, ie pressure sores, etc

    For ROV purposes:
    HEENT: HA, dizziness, syncope, presyncope, fatigue, weakness, cough, nosebleeds
    Chest: CP, SOB, DOE, PND, orthopnea
    GI: n/v/d
    Extrem: neuro, edema, & depends upon how detailed you wanna be.

    hope it helps.
  7. by   AfloydRN
    Start w/ the head and work your way down. Every system is covered.
  8. by   GatorRN
    i've always found it easier since i'm doing a head to toe assessment, to chart from head to toe. by doin so all systems are covered. such as:

    vitals
    loc/a&o
    eyes/perrla
    skin/dressings
    lungs
    abd
    pulses
    mae or not
    any iv's, o2, ng....etc
    foley/drains
    teds/scd
    safety....bed low, rails up x2 etc...

    hope this helps...this way has just always been easier to remember for me, rather then breaking down systems.

    ________________________________

    go gators!! 1/8/7 ~ 41-14
    national champions!!
  9. by   MARIAN202
    neurological Assessment
    Alert And Oriented To Person, Time
    Behavior Appropriate To Situation And Memory Intact
    Extremities With Symmetry Of Strength
    No Numbness Or Parathesis; Face Symmetricial
    Vebalization Clear And Understandable

    cardiovascular Assessment
    Regular Rhythm, Rate 60-100/min, Bp Stable
    No Peripheral Edema
    No Dizziness, Chest Pain Or Pressure

    respiratory
    Regular Rate 10-20/ Min
    Breath Sounds Clear And Unlabored
    No Sputum Or Sputum Clear, White, Or Pale Yellow

    gastrointestinal
    Abdominal, Soft, Non-distended With Bowel Sounds
    Bm's Within The Last 3 Days Prior
    Light To Dark Brown, Formed Stool
    No Emesis Or Diarrhea

    nutrition
    Taking Average Of 75% Diet Over Last 3 Days.
    Tolerating Food And Fluid.
    No Difficulity Chewing Or Swallowing Or Mouth Pain

    genitourinary
    Urine Clear To Yellow.
    No Signs Current Infect.,drainage, Trauma, Bleeding, Retention.

    musculoskeletal/mobility
    No Redness, Swelling Or Deformity
    Normal Rom Of Extremities

    integumentary
    Skin Color Within Patient's Normal, Afebrile.
    Skin Dry And Intact With No Rashes, Lesions Or Ecchymosis.

    intravenous Assement (all Sites)
    Site Without Signs Or Symptoms Of Redness, Swelling, Or Pain
    Dressing Dry Intact
    Cath Is Intact When Discontinued

    pain Management Assessment
    Pain Free (obtain Order If Needed)

    surgical Site
    Incision Edges Approximated If Visible
    No Evidence Of Inflammation Or Purlent Drainage
    Sutures, Staples, Steri Strips, Dressing Dry & Intact if Applicable

    knowledge And Education Assessment
    Demonstrates Readiness And Willing, Capability And Resource To Learn About Condition And Self Care
    Understands Diagnosis And Treatment Plan
    States Understanding Of Verbal Or Written Instructions

    discharge Planning
    Able To Manage Adl's Without Difficulty, Or Has Adequate Support System In Place
    Able To Return To Previous Living Situation.

    psychosocial Asessment
    Appropriate Behavior For Condition And Age Range
    Cooperative With No Signs Of Distress, Or Depression, Manageable Anxiety

    tubes/equipment (if Present)
    Ct To Water Seal 20 Cm Suction Drains Serosanguious Fluid, No Air Leak.
    Ng In Place Draining Greenish-brown Fluid, Irrigates Well If Ordered.
    Foley Cath Drains Clear Yellow Urine.
    Hemavac/jp In Place, Compressed, Draining Serosanguious

    If Referrals Made, Order In Computer And Record On Top Rand,
    Computer Ord:
    Social Services
    Social Services (update)
    Dititian Referral And Nutrition Score
    Last edit by MARIAN202 on Jan 20, '07

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