didcharge nsg note

[fatdaddy]

can someone please tell me what a generic discharge nsg note contains

[MAISY, RN-ER, BSN, RN]

Medical diagnosis. Medications prescribed and how to use them. Follow up instructions. Referrals to specialists, outpatient in house help and PT. Possibly current condition-care of drainage devices, wound care, crutch or cane walking, splints/cast care etc.

Pretty Basic Stuff.

Maisy;)

[TexasPediRN]

My generic d/c note looks something like the following:

(I work Pedi)

"Patient and family ready for discharge per MD orders. IV DC'd and bandage applied. D/c instructions reviewed with family, verbalize understanding. Encouraged to call MD with any questions or concerns. Aware of need to set follow up appt and verbalize understanding of all medications. Patient and family left at this time with all belongings, RX and discharge instructions to private transportation at this time"

[Agnus]

Gave verbal and written discharge instructions with handouts and scripts. Pt verbalized understanding.

Of course if I had to do teaching of a skill I specifically mention the skill and state that Pt (or who ever) was able to give a return demonstration.

Generally skills are taught well before discharge so that on the actual discharge note the most you might need to mention that the pt gave a successful return demonstration.

I keep it brief. I was taught if I am ever taken to court I would of course have to explain in detail what discharge teaching consisted of. Then I would talk about the medication teaching, s/s of infection and anything else that might apply to this specific dx.

There are certain things to each dx that the teaching is the same. Where something is a bit different from routine for that dx you should talk about it specifically.

In your written dc instructions include everything you actually talked about barring what is covered in any handouts you give them.

[MAISY, RN-ER, BSN, RN]

Sorry, Didn't think of it as a final note....was thinking of paperwork given to patients.

In ER, our charting is done on computers, so for say ankle sprain: dx of ankle sprain, RICE, crutch walking instructions, meds prescribed would be printed along with referral. The note on the actual discharge paperwork may look like this. DX: Ankle sprain. Keep leg elevated. Follow RICE therapy. Take medications as ordered, follow precautions. Follow up with PMD and Orthopedist in 1-3 days. Return to ED if numbness, increased pain, or for any additional concerns.

My final nursing note would be something like this. Perform crutch walking with patient with return demonstration. Patient ambulating steadily and state "they feel fine using crutches". Patient stable, pain relieved. Patient able to move toes, foot warm, +pedal pulse-splint care and precautions explained. Discharge instructions administered-patient to follow up with physician.

Maisy;)

[ckc6977]

My d/c note looks something like this.

D/C instructions as follows. Advised pt of no added salt diet c examples of foods to eat/avoid. Explained to pt he may begin driving in 4 days. Discussed and reviewed medications. Rx given for Metoprolol, Colace, Percocet. Discussed side effects and written information of aforementioned medications. Advised f/u c Dr. White in 7-10 days. Pt verbalized understanding c all questions answered. Pt's wife present during time of d/c teaching. D/c'ed telemetry per MD orders, turned in to "me", MCT. D/c'ed IVAD, catheter appears intact. Applied gauze & tape to control bleeding. Advised pt if bleeding occurs to hold pressure and elevate extremity.

I usually write another note stating how the pt left, for example.

Pt left floor via w/c c me, NCA and pt's wife. Pt left in stable condition.

Hope this helps!

[TigerGalLE, BSN, RN]

I usually say something like this...

D/C instructions, Medlist, Rx, f/u appointments given to and reviewed with patient. Pt. verbalized understanding. 20g IV gelco removed from R hand; tip intact. No bleeding noted. Opportunity for questions provided. Pt denies questions or concerns. Pt awaiting ride from daughter.

Pt escorted to D/C area via W/C by CNA. Discharged with daughter to return home. No distress noted.

now if it is a more complicated discharge.. say sending a patient home on insulin...I would include all the teaching and return demonstrations that we did.... Or if I am sending a patient home on insulin that has been on insulin at home I would chart that the patient verbalized that they had a glucometer and test strips at home and that they understood how to manage diabetes.. using examples and direct quotes... Always CYA... haha

Esp with our noncompliant pt's. I always chart that they verbalized the importance of getting their Rx filled and taking medicines as prescribed and how they would go to their follow up appointments.

Your discharge note is going to be different for each patient. Just say what you need to say so that you know you covered yourself. And always chart that you gave the patient their Rx... so they can't try to say you didn't...

Tiger