Rehab Nursing Documentation

Nov 06, 2009 01:31 AM

by ndyclh

__________________________________________________ ____________________

06/11/09, 1130hrs
NURSING (AM)

G/C: Conscious and alert. Sat out during shift.
FP observed and maintained. ADL assisted.
On O2 – SPO2: 100% on 2L via Nasal Prong, 95% in RA.
NGT sited on (L) nostril, insitu. Feeds tolerated well.
(L) Knee and shin dressing, dry and intact.
Dressing due EOD, to change cm. STO to be done.
Today’s Changes:
(H): 15/11/09
24H Urine collection for UTP:
Preservatives obtained.
Urine collection started @ 1100hrs, to end cm @ 1100hrs.
To note total urine volume.
Bld for inx (HbA1C) to do. – Form Labelled
Outpt Lifecare to obtain upon d/c.
To continue caregiver training on NGT Feeding.
VFS arranged on 11/11/09 @ 1500hrs

RN JOSEPH @ 1145hrs
__________________________________________________ ____________________

06/11/09, 1200hrs
SPEECH THERAPY

ST Order:
1) FM Diet ½ Share
2) Cont’d NGT
3) R/V after VFS, 11/11/09
ST Input:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X

ST MARY @ 1210hrs
__________________________________________________ ____________________

06/11/09, 1300hrs
NURSING (AM)

S/B ST, to note input:
FM Diet ½ Share, taken well. Nil coughing seen.
Feeds @ 1200hrs omitted, pt taken ½ share FM diet.
To resume feeds @ 1500hrs, as scheduled.
Caregiver training on NGT Feeding:
Family arrived ward @ 1230hrs. Procedure revised with family.
Pt’s wife did some hands-on. Explained to them the importance
of checking tube position prior feeding and complication.
Caregiver competency Ax:
Family – seems to be +ve and forthcoming towards VFS that
pt doesn’t require NGT. Enforced to family that caregiver need to
be competent before VFS, in case pt has to be d/c with NGT.
Wife – Not familiar with procedure and was distracted easily,
require prompting++ despite yesterday’s session.
Pt – Able to prompt wife in procedure and understood feeding
complication.
Caregiver Training Plan:
To continue training and Ax as arranged, cm @ 1200hrs.

RN JOSEPH @ 1315hrs
__________________________________________________ ____________________

06/11/09, 1345hrs
NURSING (AM)

Bld for inx (HbA1C), taken and desp @ 1330hrs.
1330hrs: Acupuncture Centre called to send pt for acupuncture
cm @ 1000hrs. To e-Porter cm.

RN JOSEPH @ 1145hrs
__________________________________________________ ____________________

ndyclh · Nov 06, 2009, 01:44 AM

Re: Rehab Nursing Documentation

Dear nursing-mates,

I've been reading very similar and generic nursing report in both acute and rehab setting. I'm new to the Rehab Department and i believe that there's something that's unique here. As we were taught, "Care not documented, is not given". I need to re-learn on a new way of documentation, so i tried to be specific.

I would require your help here. Please advice me on a more specialised rehab nursing documentation. Kindly provide examples/format on documentation. Or even feedback mine.

What i did was:
1) General Condition and overal appearance of patient
2) Doctor's orders for the day
3) Any update/events in chronological order.

I believe there's more to it, in terms of a proper assessment and rehab terms.
For example, transferring assistance, FIM, etc.

SitcomNurse · Nov 06, 2009, 06:10 AM

Re: Rehab Nursing Documentation

For more accurate rehab documentation, I you should
1. Know what the person is in the unit for.
2. read the PT/OT/ST evaluations and treatment plan(STG/LTG)
3. document if the "independent exercizes' are being done. "res performing AROM as per PT recommendations"
4. document if the ability to SPT is requiring Min/Mod/Max assist according to the specific plan of care.
5. document that you are encouraging them to do the things recommended, as part of the plan.
6. document effectiveness of the 3 above items. 'resident able to....." or "resident not able to...."

The idea behind the documentation is that the efforts of PT and OT are enhanced and encouraged when they are not in the formal therapy. This is when Nursing Rehab is pertinent. We have the patients for the other 10 waking hours of their day.

If you use the MDS language for limited/extensive/total assist, it is all about weight bearing, and therefore, correlate with the min/mod/max assist of formal therapy.

The three points you expressed are pertinent in a Nursing perspective, absoloutely. When doing Rehab though, we can be better served by correlating our notes with rehab.
This will also reduce the amount of "decline to pay" from a reimbursement perspective.

In my role, I write notes that affirm the residents need for greater therapy than simply Nursing Rehab. I will describe the gait in terms the therapists use, but in my own nursing language ("crosses legs when ambulating" instead of scissor gait, "drags heels" insted of describing the motor function) just write what you are seeing visually in simple terms, and it will back the therapists evaluation.

Resident with short shuffling steps during ambulation to toilet. Leaning to weaker (L) side. Rolling walker in use for ambulation. Resident able to adjust clothing with 1 assist to regain pants to waist.

Resident able to feed self with adaptive equipment provided by OT department. Assist with opening containers, and cutting food. Noted shaking of R hand (dominant side) during process. Weighted utencils in use.

Good luck to you.
Sitcom Nurse
Sometimes God turns on the Sitcom Nurse channel. Its like Comedy Central for Her.

ndyclh · Nov 06, 2009, 08:06 AM

Re: Rehab Nursing Documentation

Appreciate for the indepth information on rehab nursing, it will definitely benefit me. But there's a few things i need to crack my head on. If you can "write" a simulated rehab nursing report, it will be good.

There's a lot of rehab terms i need to learn. Our hospital will be organising a rehab induction program to train rehab RNs. However, that will be another x6/12 before i attend. So far, i'm the one and only new nurse there. It's pretty frustrating not able to understand the PT/OT report and conduct the rehab interventions as ordered for pt.

How do you write a report? Or do you just tick and sign on a care plan checklist?

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Rehab Nursing Documentation

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