Help Needed - Rehab Nursing Clinical Documentation Guide

  1. Hi All

    HELP NEEDED

    Does anyone know of a good documentation guideline for progress noted. One that will work in a rehab setting. We get pressured to use a acute model (Head to Toe or Systems approach) and that doesn't really work.

    I would love your ideas

    Thanks

    Rehab Melbourne
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  2. 1 Comments

  3. by   aspiringrn1987
    I do if this is helpful or not, but it depends on the patient. A note for me would say something like "Patient is A/Ox3, able to voice wants and needs. Takes meds whole and tolerates them well. Patient c/o pain this AM and was medicated with PRN norco per orders with effective results. Lung sounds clear bilaterally to auscultation with no cough or SOB noted. Bowel sounds active x4 quadrants, abdomen is soft and non-tender. Patient requires extensive assistance with ADLs. Continues on PO cipro 500 mg daily for UTI. No s/s of adverse effects from ABT. Respirations unlabored, no body rashes and patient remains afebrile. Patient has 200 mL output clear amber colored urine, offers no c/o dysuria during this shift. Patient continues on neuro checks following fall on 5/12. ROM remains unaffected, vital signs WNL, and patient remains A/O x3. Will continue to monitor."
    Last edit by aspiringrn1987 on May 14 : Reason: Typos

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