need help w/narrative note

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In stating in my narrative notes that my pt has a distended abdomen...is 'abdomen distended' enough? When I informed my instructor she asked me why I felt it was distended and I explained how the skin was stretched and how it looked but I'm not sure if she was just making sure that I knew what a distended abdomen should look like or that I need to make sure I'm more descriptive in my notes...I mean I really feel like 'distended abdomen' explains itself...I go into more detail in these notes as a whole but I feel like I'm too wordy as it is, definately my biggest problem. Today was my fourth clinical day so it's getting better. Anyway, what do you think?

thanks,

Ginyer

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In stating in my narrative notes that my pt has a distended abdomen...is 'abdomen distended' enough? When I informed my instructor she asked me why I felt it was distended and I explained how the skin was stretched and how it looked but I'm not sure if she was just making sure that I knew what a distended abdomen should look like or that I need to make sure I'm more descriptive in my notes...I mean I really feel like 'distended abdomen' explains itself...I go into more detail in these notes as a whole but I feel like I'm too wordy as it is, definately my biggest problem. Today was my fourth clinical day so it's getting better. Anyway, what do you think?

thanks,

Ginyer

A good way to be a little more descriptive but not to wordy is chart abdomin distended with abdominal girth of ___ inches at umbilicus.

Hope this helps

Donna

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I think wordy is good to an extent. You need to clarify the description of abdomin distended........is it hard soft, rounded, flat, masses noted, bowel sounds, red, has wounds, echymosis. Do you get in trouble for too many words? The more words the better the picture. Have a good day... :p

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In stating in my narrative notes that my pt has a distended abdomen...is 'abdomen distended' enough? When I informed my instructor she asked me why I felt it was distended and I explained how the skin was stretched and how it looked but I'm not sure if she was just making sure that I knew what a distended abdomen should look like or that I need to make sure I'm more descriptive in my notes...I mean I really feel like 'distended abdomen' explains itself...I go into more detail in these notes as a whole but I feel like I'm too wordy as it is, definately my biggest problem. Today was my fourth clinical day so it's getting better. Anyway, what do you think?

thanks,

Ginyer

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abd soft/hard, distended/nondistended, BS active/nonactive x 4? hypoactive/hyperactive/absent? that's all I do for a normal patient, if there's something off, you need to address it

if it's distended...did you feel a mass, did it feel hard? if so where ? you said the skin is stretched, where? over entire abd? is pt just fat? if so, just put abd distended

I had trouble being too wordy at first as well. It's good to be descriptive, but to the point.

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Thanks, I just ended up stating abdomen distended hypoactive bowel sounds x 4 tender on palpation in blah blah etc. ...I should have gone into more detail about it ... I think she just had bad gas though ... but i would think a lot of gas would give out some bowel sounds ... anyway thanks for the help, yes we get marked off for being too wordy ... the instructor is totally not impressed with my narrative notes so I'm really trying to work on that ... plus I make stupid mistakes on my charting, the one I turned in today (not real chart) I wrote the wrong date on every page and had to scratch and void, also the wrong AM BP and the wrong code number for the lung sounds I heard. I'm trying to pay attention so I don't look like a complete moron... :zzzzz I think I'm just really sleep deprived, but I guess aren't we all.

Ginyer

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