documenting

Published

hi all i was wondering if someone could help... i am currently in the lpn course and we are staring clinicals we have to do practice chartting on our patients mine had foot drop in the left foot how would i document tihs when checking for homans?? OMYGOSH i hope this makes sense what i am asking

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

to describe the foot drop i would chart, "patient maintains left foot in plantar flexion unless supported." if you are able to perform a homan's test, which is passive dorsiflexion, on the left leg, merely chart whether or not the patient has pain or not when performing the test, so, "no calf pain to passive dorsiflexion of left foot" or "complains of calf pain with passive dorsiflexion of left foot." your instructor may also accept "negative homan's sign left foot" or "positive homan's sign left foot." if the patient has a contracture deformity of the left foot from the foot drop i would chart, "unable to perform homan's test in the left lower extremity due to plantar flexion contracture of foot."

here are some links to help you with documentation. the first link is a list of medical terms related to body positioning and movement that are useful to know when describing positions and movements of parts of patient's bodies. the other two are articles about documenting nurses notes.

http://mywebpages.comcast.net/wnor/terminologyanatplanes.htm - this really is more for someone taking anatomy, but it is medical terminology. the site the shows and tells you the anatomical planes of the body, defines terms of relation or position, defines terms of movement, and has a listing of frequently used medical terms in anatomy with their definitions. a reference you might want to print out for your anatomy notebooks.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=393 - "document it right: a nurse's guide to charting".

https://nursing.advanceweb.com/common/ce/content.aspx?courseid=251&creditid=1&cc=36532&sid=1095 - documentation. an article from advance for nurses

Up Vote Up Vote ×
Specializes in Critical Care.

Daytonite, thanks for posting those links to the articles about documentation. I'm still in nursing school, and my classmates and I are always saying that we ought to have a course in documentation. Those articles were very helpful.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

You are welcome. I'm glad you found them helpful.

Up Vote Up Vote ×

ty soo much!!!! this is very helpful ;) this place is awesome

Up Vote Up Vote ×
+ Join the Discussion