Charting documentation-Did I do it correctly?
Featured Replies
Currently Reading 0
- No registered users viewing this page.
View in the app
A better way to browse. Learn more.
A better way to browse. Learn more.
A full-screen app on your home screen with push notifications, badges and more.
My instructor asked us to chart this scenario in 3 different ways. She didn't give any examples on how to do it and there wasn't much for examples in our book so I was wondering if I did this correctly and if I could get any feedback on anything I could change? The narrative note was the one I wasn't sure about at all.
Thank you!!
Charting Scenario
Problem: Angina (Chest Pain)
Mr. Cardio, an 88-year-old nursing home resident, c/o sudden, sharp chest pain at 2100. He states that it feels like an elephant is sitting on his chest. After examining him, you note the following: constant midsternal pain, diaphoresis, BP 178/98, P 120 and irregular, R 26. He has a Hx of CAD (coronary artery disease) and has taken nitroglycerin in the past for angina. You give him nitro sublingual x3 which does not relieve the pain. It is now 2120 and you call the physician on call who orders 02 at 2 liters per nasal cannula and requests transfer to the hospital per ambulance.
*Chart a narrative note, SOAP note and a focus note related to the situation above.
Nursing Notes
Narrative Note (3 pts.):
[TABLE]
[TR]
[TD]9/17/15[/TD]
[TD] Mr. Cardio c/o heaviness and sudden, sharp chest pain.[/TD]
[/TR]
[TR]
[TD]2100[/TD]
[TD] Stated that it feels like an elephant is sitting on my chest.â€
–G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD]2105[/TD]
[TD] Performed an assessment and observed constant midsternal pain,[/TD]
[/TR]
[TR]
[TD][/TD]
[TD] Diaphoresis, VS BP 178/98, P 120, R 26, and irregular pulse. Hx of [/TD]
[/TR]
[TR]
[TD][/TD]
[TD] CAD and has taken nitroglycerin in the past for angina.
–G.Thompson, S.N. [/TD]
[/TR]
[TR]
[TD]2110[/TD]
[TD]Administered nitroglycerin sublingual x3. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD]2120[/TD]
[TD]Medication was not effective. Contacted physician on call. Ordered [/TD]
[/TR]
[TR]
[TD][/TD]
[TD]02 at 2L per nasal cannula and transfer to hospital via ambulance.
–G.Thompson,S.N. [/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD=colspan: 2][/TD]
[/TR]
[/TABLE]
SOAP Note (4 pts.):
[TABLE]
[TR]
[TD]9/17/15[/TD]
[TD][/TD]
[/TR]
[TR]
[TD]2100[/TD]
[TD]S: C/O sudden, sharp chest pain. Stated it felt like an elephant was [/TD]
[/TR]
[TR]
[TD][/TD]
[TD]sitting on his chest. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]O: constant midsternal pain, diaphoresis, BP 178/98mmHg, pulse [/TD]
[/TR]
[TR]
[TD][/TD]
[TD]120bpm and irregular, respirations 26bpm. He has a Hx of CAD. [/TD]
[/TR]
[TR]
[TD][/TD]
[TD] –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]A: Administered nitro sublingual x3. Did not relieve pain. [/TD]
[/TR]
[TR]
[TD][/TD]
[TD] –G.Thompson, S.N. [/TD]
[/TR]
[TR]
[TD]2120[/TD]
[TD]P: Notified physician of change of status r/t chest pain and VS.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]Ordered O2 at 2L per nasal cannula and requested transfer to[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]hospital via ambulance. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[/TABLE]
Focus Note (3 pt.):
[TABLE]
[TR]
[TD]9/17/15[/TD]
[TD]Data: C/O sudden, sharp chest pain. Stated that he felt like an[/TD]
[/TR]
[TR]
[TD]2100[/TD]
[TD]elephant is sitting on his chest. Observed constant midsternal pain,[/TD]
[/TR]
[TR]
[TD]Focus:[/TD]
[TD]diaphoresis, BP 178/98mmHg, pulse120bpm and irregular,[/TD]
[/TR]
[TR]
[TD]Chest pain[/TD]
[TD]respirations 26bpm. Hx of CAD. Taken nitroglycerin in the past for [/TD]
[/TR]
[TR]
[TD][/TD]
[TD]angina. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]Action: Administered Nitroglycerin sublingual x3. Medication[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]not effective. Contacted physician on call. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD]2120[/TD]
[TD]Plan: Ordered 02 at 2L per nasal cannula. Requested transfer[/TD]
[/TR]
[TR]
[TD][/TD]
[TD]to hospital via ambulance. –G.Thompson, S.N.[/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[/TR]
[/TABLE]