Documentation

[AussieTina]

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.

[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