Question about documentation

  1. An LPN student with a documentaion question- Working on head to toe assessments right now & wonder if you have any certain ways of wording what you find, the routine stuff, I mean. Things you'd probaly write each time. My instructor gave the example of "lungs clear to auscaltation bilaterally A&P"
    How would you word "normal" findings?
    Dixie
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  2. 11 Comments

  3. by   Altra
    Examples of normal findings in other systems, in addition to the one your instructor gave:

    Abd soft, non-tender to palpation, active BS x 4

    Pt. moves all extremities equally, full ROM noted, hand grips equal bilaterally

    Quick & steady gait observed

    Skin warm & dry, good color, no abrasions, lacerations or other areas of breakdown noted

    Apical pulse strong & regular, radial & pedal pulses easily palpable

    Other normal respiratory findings - pt. speaks in complete sentences without dyspnea, no cough, no peripheral cyanosis, no accessory muscle use noted

    Hope this helps.
  4. by   dcnballmom
    ok here one for you - if a patient falls and the floor is wet - do you document that it is urine or just say wet floor?
  5. by   Altra
    Quote from dcnballmom
    ok here one for you - if a patient falls and the floor is wet - do you document that it is urine or just say wet floor?
    Unless you witnessed the pt. falling, you simply state, "Pt. found on floor in (x) position." You can state, "liquid noted on floor, odor of urine noted"
  6. by   mamason
    Alert and orientated X3. Lungs clear with even and unlabored breath sounds.o2 saturation 98% on room air. Bowels sounds present, Non tender to palpatation x 4 Quads. Extremities strong x4. No edema present. Pedal pulses 2+ bilaterally. Pt denies sob, cp, or dizziness at this time. tele monitor shows SR 80's. Vital signs stable. See graphics. # 20 to the right forarm saline locked. Assessed and flushed. Dressing dry and intact. No edema or leakage at IV site noted. Pt up to bathroom with stand by assist. Steady gait noted. Ambulation tolerated well. Pt voiding clear yellow urine. BM x 1 this am. Pt denies pain at this time. CHF education reinforced. Pt states understanding. Bed remains in low locked position with call light and bed side table with in reach. pt resting comfortably in bed. Spouse at bedside.
  7. by   loricatus
    A&0 x 3, Neuro assmt WNL. Denies pain/discomfort. Resp even, unlabored, lungs CTA, 98% O2 sat RA. Skin pink, warm, dry, intact, Cap refill < 2sec.,- edema, MM moist. Abd soft, nondistended, nontender, BS X 4q. MAE= c FROM, gait even, steady. IVL s s/s infiltration, NS infusing well @ 100 ml/h. Foley draining well, clear yellow. Educ. r/t plan of care, meds, procedures provided. Safety maintained.
  8. by   meandragonbrett
    AA&Ox3, PERRLA, Resps Even/Unlabored, lungs CTA bilaterally. Bowel Sounds Active x4, Abd soft, non-tender, Skin warm, dry, intact. MAE to command equally. Radial Pulses 3+ Bilaterally.....and so on and so on........ Foley patent to bedside drainage. #18 R A/C patent s s/sx of infection. D51/2NS@75cc/hr. Resting quietly in bed, no verbalized c/o, bed in low position.......There's so much you could say. I don't generally chart *normal* stuff in my narrative just on the flow sheet. Only abnormal or equipment that is currently in use.
  9. by   midcom
    Thank you all so much. These will really help me to figure out how to word my findings. I think this is harder than the actual assessment.
    Dixie
  10. by   mamason
    As you can see, everyone has their own way of doing documentation. Like one of the other poster's stated, I usually only document abnormal findings. The normal findings are on a med tech system that we use at work. It's computerized charting. Or, usually the flow sheet is checked off on normal findings. Then, you can add anything that is out of the ordinary as you go. It just takes a while to get used to what to write. It will come. You just have to do it a couple of times to get into the swing of things.
  11. by   JennieO
    A&P. I do not think so. We are rapidly losing our abbreviations yearly. Unfortunately, many instructors are far removed from the act of nursing.
  12. by   suzanne4
    I always find it easier to start at the top, and work down. Easier for anyone to remember.

    Neuro
    CV
    Resp
    GI/GU
    Extremities

    Have found that students always find it easier to do it this way.
  13. by   midcom
    Quote from JennieO
    A&P. I do not think so. We are rapidly losing our abbreviations yearly. Unfortunately, many instructors are far removed from the act of nursing.
    I'm not sure I understand. Is "A&P" (anterior & posterior) no longer used? I know that several abbreviations are no longer used because of confusion. All my instructors also work part time in hospitals or are taking additional training. This particular one is working on becoming a nurse practicioner, about to get her masters. Perhaps some abbreviations are not used in certain parts of the country??? Interesting.
    Dixie

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