Nurses notes query

Are you doing a care plan?

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.

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...

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.

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.