reporting

  1. Hello
    I hope someone can help we have to write a legally compliant report for the following observations this is part of our assignment.
    This is the way it is written
    Jane Gray
    #R)NOF
    R22
    c/o pain
    P 92
    BP 190/110
    so please if anyone could give me some ideas on how this is done.
    thanks
    Anne
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  2. 2 Comments

  3. by   EricJRN
    Would really need to know more about the location and nature of the pain to document anything of value. I think there may be an error in the line under the patient's name - at least I can't make out what it's saying.
  4. by   Daytonite
    i get the complaint of pain and the set of vital signs. but i don't understand what "#r)nof" means. there is a big movement underway here in the u.s. to avoid using abbreviations for the reason that so many places make up abbreviations that could mean one thing to their facility and something else when being read by someone else.

    in most places i've worked the vital signs would be put into a graphic sheet. to expand on what ericenfermero has said, when you chart about pain, you want to address:
    • what the patient says the pain feels like
    • where the pain is and if it radiates to other parts of the body
    • how severe the pain is and this is often done by asking the patient to evaluate it on a scale of 1 to 10
    • determining when the pain begins
    • is the pain intermittent or constant
    • what makes the pain better; what makes it worse
    here are websites where you can see some samples of narrative nurses charting:

    http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. it is for a patient with a recent cva.

    http://allnurses.com/forums/f205/exa...ng-138835.html - links to examples of charting

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