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Discussion

How would you document

I need help with my documentation. I have a patient with hip pain. The pain is in the right front at the hip area.

So to me what I am documenting sounds stupid, so I need help.

This is what I put:

Pt. C/O constant pain @ Anterior Right hip X 3 days. + Clicking, +Popping,

- inflammation/redness, - grinding. Pain 7/10 on pain scale. Ibuprofen has not helped to relieve.

Is it right to say anterior or is there another word to explain location? What if she would have pointed to her side or her posterior area?

Does that cover what I need to cover?

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Better than what I've seen from other people (ex: Pain in right hip).

Clicking and popping with movement?

Pulses, motor and sensation distal to pain?

Pain increase or decreased with anything?

Further descriptions on pain (ache, dull, sharp, stabbing...)

Want me to get more anal? :chuckle

I work in a Cancer Centre. To help with this problem, we have anterior, posterior & lateral outlines of the human body, each taking up about 1/2 of an A4 size paper. Patients can point direcly to the area were they have pain and the nurse will shade this in & put it in their permanant record.

Could you just draw a rough outline of the human form & shade in the areas? Cuts out any ambiguity

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