Published Jul 21, 2009
Good afternoon colleagues. With the Joint Commission focusing on certain aspects of documentation, I was wondering how specifically any of you document patient goals for their ED visit.
Do you free text -- do you have a nice pre-written documentation tool that you use?
I am currently working to develop a documentation system that must include patient- goal setting. I certainly can put together a query that just says-- fill in the patient goal (s) and then another that asks if they were met---but I was hoping that some of you had great ideas or things that you use that I could utilize in OUR documentation
Thanks for your help!
Goals-- already suggested (pain, relief of symptoms, diagnosis of problem)--
I'm an ED nurse and I have no idea what you mean by goal setting documentation. Do you mean core measures? Or do you mean adequate pain control, discharge teaching, etc.? I really am curious as to what you mean!
Our director wishes to add to our routine documentation--patient's specific goals on WHY they came to the ED. And then--after this is identified, to document how well we met thios goal.
It's not really NPSG oriented--(of course we have our core measures stuff still), it's just an additional focus on what the patient wants to accomplish while they are in our care..
I'm looking on line to see if any other nursing units document this way and maybe explain it a bit more eloquently--
I'll see what I can find
This is kind of what I'm getting at--that our assessments include pts' goals as well as we assess physiological systems
Patient teaching is a real biggie I can see here. For example, prevention education (to prevent future needless ER visits for oh, say signs of a viral infection vs. bacterial infection or diabetic teaching for control of blood sugars to prevent future loss of limb/eyesight kinda stuff).
Daytonite, BSN, RN
goal setting sounds very similar to soap(ie)® charting where a plan of action is formulated. soap charting is problem-oriented. the "p" is the plan for relieving the patient's problems, including short term and long term actions. this thread contains an example of a soap note: https://allnurses.com/general-nursing-discussion/how-make-soapie-253110.html - how to make a soapie note
The system in our ED has a section in nurse's notes called outcomes, followed by a section that says discussed plan of care, goals met/not met. Then 8-10 fields r/t education, vitals assessed, neuro vitals, and a section for rx, crutches, etc.
Lunah, MSN, RN
We have an "outcome" section as well. One of my favorites is "Pt. will maintain hemodynamic stability." I find myself using that one often! And "pt. will verbalize a decrease in pain/symptoms/whatever." It's a free-text box in our electronic charting program, by the way. (We use PICIS/ED PulseCheck.)
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