Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Nurses notes query

I have a question and I would like some opinions or maybe have knowledge that I don't. If my pt is diagnosed with static epilepsy and has anoxia with the seizures. Can I use seizures in my documentation because I know usually seizure is a medical diagnosis but if the actual medical diagnosis is static epilepsy woudnt a seizure be a symptom and therefore allowed in documentation?

  • Quote

    • Featured Replies

    Are you doing a care plan?

  • Quote
    • Author

    No sorry this is my first time posting and I clicked the wrong category I think. Oh also, I'm not classifying the seizure into tonic clinic or absence just stating " pt had seizure at 0234" then writting my assessment of the pt during the seizure.

  • Quote

    Why can't you write tonic or absence or atonic or clonic seizure. Epilepsy or convulsions is the medical diagnosis. The observations of seizure activity (07:35 30-second tonic seizure, head to right, stiffening of extremities, gaze right, horizontal nystagmus, shoulders shrugging with clonus of extremeties. HR 110, RR 32, SpO2 98% on 2LPM O2, seizure precautions maintained...

  • Quote

    ah ok --- that's probably why I'm a bit confused... I'm assuming that you mean that the patient has a history of status (not static) epliepticus - defined as either prolonged seizure activity or multiple seizures without the patient recovering in-between. Also, seizure is not a medical dx rather epilepsy is. There are many things other than epilepsy that could cause one to have a seizure.

    If you actually witnessed the seizure activity, then it would be perfectly valid for you to use the word "seizure" in a narrative.

  • Quote
    • Author

    Sorry yes I ment status I'm using my phone and likes to change my words lol and thank you that's what I thought . I was told that I could not classify the seizure or call it a seizure cause that is a medical diagnosis by my company. Which I thought it sounded off to me.

  • Quote
    • Experts

    Moved to general nursing discussion

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.