discharge documentation

  1. Hi, I've been working on the floor for 6 weeks now and I'm still trying to fine tune my discharge documentation so far it goes something like this:

    40yr old male presents to ED with HA, N/V, Chest Pain.
    Hx: none
    Allegies: NKA

    medications taken PTA: pepcid, tylenol

    diagnostics performed: CBC, BMP, CK, Trop, ECG, CXR

    medications given: Zofran 4mg, Motrin 600mg

    Discharge diagnosis: Acute abdominal pain, cephalgia

    labs normal, ECG normal, no acute abnormalities on CXR

    Discharge note:

    "DC'd pt from ED c family. AOx4, Respirations even and unlabored, skin pink, warm and dry, ambulatory with steady gait, still c/o pain in abd LUQ 8/10 burning, tolerable, no c/o nausea or HA, NAD, VSS, afebrile. IV DC'd tip intact, dressing applied, pressure held. After care instructions provided and explained. Copies of lab results and ECG provided. Left ED with all belongings."

    is there anything else I should include. my preceptor is always saying i need to "paint a picture"

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    About deliverator, ADN, BSN, MSN, RN

    Joined: Mar '07; Posts: 98; Likes: 32
    RN, VA Long Beach SCI/D HCG; from US
    Specialty: 8 year(s) of experience in Spinal Cord Injury


  3. by   MsTosh, RN
    Im a new graduate as well and im trying to get a handle on my documentation. Heres, an example of a discharge note out my charting book.

    68y.o. black male admitted 5/2/10 with chest pain, HTN; BP 190/100, and SOB. MI ruled out. Chest pain relieved with sublingual Nitroglycerin and O2. Persantine thallium performed 11/30. Tolerated procedure well. Has been OOB ambulating in the hallway without chest pain or SOB since 11/30. BP remains stable (144/86 at 12:30noon). Drug regimen includes daily aspirin 325mg, and captopril 25mg b.i.d verbalized understanding of medication times, dosages, and adverse effects. Will call Dr T Harris for 10 day post discharge appointment. Discharge instruction sheet given. Pt escorted via wheel chair all belonging sent with patient.

    Im gathering a discharge note is the care and diagnostic test the patient recieved from the begininng of he/she arrival to discharge. This gives a detail picture of the patients prognosis is he or she getting better or worst.

    Thats just my guess, im a new graduate as well. lol
  4. by   MsTosh, RN
    the book I have is "Charting Made incerdibly Easy" 3rd edition Lippinocott Williams and Wilkins. I love this book it really helps with nurses notes and it also display some of the forms you may encounter.