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  1. Hello peoples

    I am currently doing a three week clinical placement in a paediatric ward in a QLD hosp, and loving every second that i am there. However i am struggling when i am writing in the patients chart at the end of the shift.

    Can anyone tell me of any tips that they might have for writing in the notes or any websites, or books that can help, especially with an aussie perspective or more specifically a QLD health one.
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  2. 1 Comments

  3. by   kidznurse
    I found a systematic approach helped me. Do top to toe assessment description using headings to jog your memory eg

    neuro: Alert and active, or lethargic and irritable. Febrile temp. 39.0c now 37.8 2 hour post paracetamol 200mg.
    integument : widespread eczematous rash to trunk and legs
    cardovascular: tachycrdic HR 180, normotensive BP 100/60, Capillary refill time = 2sec
    respiratory :Resp rate 40 sao2 97% productive cough, widespread creps on auscultation, audibly wheezy
    renal/urinary: Good clear urine, dark offensive smelling urine Elevated creatinine
    Nutrition: Eating small amounts of icecream, refusing all drinks.
    Fluid and electrolyte: Remains on IV fluids 40ml per hour cannula site satisfactory
    gastrointestinal : frequent mustard coloured stool
    musculo skeletal :
    Marked loss of tone upper limbs
    Infectious disease:
    Throat swab positive for strep A, on isolation precautions, IV antibiotics last given 1800 due 2200
    developmental:
    Playing with rattle, interacting with other children in room
    social:
    Mum very tired and needing to go home grandmother has come to sit with Ben Social worker asked to see regarding meal benefits. Mum has asked that siblings be allowed to stay in hospital. Became very agitated when advisd not unit policy and offered social work input
    Just as a bit of an example can keep you focussed

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