Nurses notes query

[Perezm]

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?

[203bravo, MSN, APRN]

Are you doing a care plan?

[Perezm]

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.

[JustBeachyNurse, LPN]

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...

[203bravo, MSN, APRN]

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.

[Perezm]

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.

[traumaRUs, MSN, APRN]

Moved to general nursing discussion