Nursing documentation help

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by tsm007 tsm007 Member Nurse

Has 2 years experience.

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tsm007

tsm007

Has 2 years experience. 675 Posts

Admission note for STEMI

"Patient admitted to XYU at 1947 via stretcher, escorted by ED RN. Report received at the bedside, all questions answered at that time. Initial assessment and vitals WNL. No complaints of pain or signs of distress at this time. Telemetry shows NSR with ST elevation. Room orientation given in detail, all questions answered at this time. Will continue to monitor."

Admissions, I put when and how they got to me, that report was received and how, a brief summary of assessment data with abnormals when present, focused assessment subjective and objective data (so if admitted for MI, telemetry and assessment symptoms of MI are noteworthy), and my POC ("will continue to assess" is my normal go-to).

For eventful shifts,

"Patient grabbed face of tech, with threat of "I will eat your face with fava beans and a fine glass of Chianti." Contacted MD; order received for PRN haldol. Haldol administered. Will await effectiveness and continue to assess for safety."

(Then in an addendum)

"Medication effective. Patient resting comfortably. Will continue to monitor."

On that note, it is what happened, what I assessed (if needed, like lung sounds in respiratory distress), what I did about it (contacted MD, etc), whether that worked (which may need to be done in addendum), what my plan is beyond that.

For uneventful shifts, I do a brief summary of their assessment, a line or two that is focused on progress on their admission reason, noteworthy education topics if education was a huge need for that patient (like new afib on anticoagulation), and that I'll be continuing to monitor.

Discharge: "Patient discharged to home. IV and telemetry removed, all belongings given. Discharge instructions given, reviewed in detail; all questions answered at that time. Escorted by transport via wheelchair to private vehicle. No other noteworthy events."

My notes don't usually get too lengthy at all. Sometimes they can get that way, though, if something noteworthy did occur. I actually had the longest admission note in history last week because the ED missed some really important time-sensitive things that I had to address. And of course, it was right before shift change, so everything that could go wrong, did.

For the post fall note, "Patient's post fall vitals and neuro assessments WNL. No complaints of pain or signs of distress at this time. Will continue to monitor for patient comfort and change in status."

Thanks for adding your ideas! They are all so helpful.

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 13 years experience. 3,878 Posts

V/S: ____________. Resident alert, verbally responsive, oriented X1-2, and able to communicate needs. No signs of acute distress. Resident resting quietly at this time with eyes closed [Or whatever resident is doing]. No signs or symptoms of pain or discomfort at this time [Or Denies pain/discomfort at this time]. Continues on PO antibiotic treatment for UTI. No adverse side effects noted. No diarrhea, N/V, rashes, or fever noted. Urine clear and yellow with no foul odor or hematuria. No complaints of dysuria. Oral fluids encouraged and accepted. Will continue to monitor. Bed in low position. Call light in reach.

I would argue that you don't even need to include the part about "PO ABX for UTI"--it would be double charting. The ABX is signed off in the MAR. The fact that they have a UTI is indicated with lab work and previous assessment. The other parts (no dysuria, no diarrhea etc.) are important, although some would argue that you don't need to chart a negative. Personally, I would think them to be pertinent negatives and charting them is a good idea.

Also, who told you that you can't chart that someone is sleeping? "Sleeping" is built in to our point and click charting, even though we very rarely verify that someone is actually sleeping and not just "resting their eyes."

tsm007

tsm007

Has 2 years experience. 675 Posts

Also, who told you that you can't chart that someone is sleeping? "Sleeping" is built in to our point and click charting, even though we very rarely verify that someone is actually sleeping and not just "resting their eyes."

I read it somewhere on AN that you should chart resting with eyes closed or "appears to be sleeping" since it's hard to verify whether they are actually sleeping.

Alisonisayoshi, LVN

Specializes in LTC. 547 Posts

Here's what I came up with for ABT and skin tears. Hope it's helpful to you. I scoured the internet working on this. It's pathetic to have to work this hard for a narrative note, but I felt so clueless. The other posters here got me off to a good start! I need to go through the admission stuff next. That's the next big one I want to work on having a template of some sort for.

ABT note

V/S: ____________. Resident alert, verbally responsive, oriented X1-2, and able to communicate needs. No signs of acute distress. Resident resting quietly at this time with eyes closed [Or whatever resident is doing]. No signs or symptoms of pain or discomfort at this time [Or Denies pain/discomfort at this time]. Continues on PO antibiotic treatment for UTI. No adverse side effects noted. No diarrhea, N/V, rashes, or fever noted. Urine clear and yellow with no foul odor or hematuria. No complaints of dysuria. Oral fluids encouraged and accepted. Will continue to monitor. Bed in low position. Call light in reach.

And skin tears

V/S: ____________. New skin tear of unknown origin found on resident at 0200. Resident has 2 x 3 cm skin tear to left elbow. Wound is dry and free from drainage, warmth, or odor. Edges well approximated. Resident rates pain at 0. Resident states he does not remember how skin tear happened. Cleansed wound with NS, applied Curex and non-adherent dressing, wrapped in Kerlix per standing order. Will notify family this AM.

And here's my post fall narrative note

V/S: ____________. Resident continues on post-fall assessment without incident. Resident alert, verbally responsive, oriented X1-2, and able to communicate needs. Resident resting quietly at this time with eyes closed [Or whatever resident is doing]. No signs or symptoms of pain or discomfort at this time [Or Denies pain/discomfort at this time]. No new areas of bruising noted. VSS. Neuro-checks WNL. Will continue to observe. Bed in low position. Call light in reach.

and discharge note

Resident discharged to home [insert where] today. V/S: ____________. Reviewed discharge instructions with resident [and insert family member]. Reviewed all medications including drug name, purpose, doses, administration times, routes, and adverse effects. Drug information sheets and a complete reconciled medication list given to resident. Resident able to verbalize proper use of medications. Teaching provided on [insert teaching] Resident verbalized understanding [or needs further instruction on …]. Informed to notify doctor if [insert when to notify doctor]. Follow up appointment with Dr. X on 1/1/2015 at 0900. [OR Resident will make a follow-up appointment with Doctor X in 2 weeks.] Wrote doctor's phone number on written instructions. Written discharge instructions and prescriptions given to resident [OR insert family member]. Belongings sent. Discharged at 1530 via wheelchair accompanied by daughter. Transported via private car [ambulance].

I apologize in advance for cross posting the charting questions on the LTC forum. Also, I did canabalize stuff from AN too along with stuff from other sites to create my little cheat sheet.

Omg I love you right now!!!!!!

margauxfd

margauxfd

32 Posts

I'm so glad that you started this thread. I'm a new nurse too starting in LTC. Thank you everyone for the tips.

Whit2389

Whit2389

28 Posts

You need to chart relevant information. If a patient fell but not on your shift then he/she is being followed up on r/t fall. You need to chart the specific situation going on, the relevant assessment findings, and interventions to prevent the issue from happening again. Falling is a safety issue. You could state something along the lines of "Mr. Smith fell yesterday at 7:00AM, neurochecks continue and are WNL. Patient in bed resting with no s/s of distress noted at thos his time. Bed is in low position and call bell within reach at all times"

If the patient were to fracture their elbow during the fall and is having pain then instead of no s/s of distress you would chart "fall resulted in a fracture of L elbow. Pt states pain level 8/10. 3mg Dilaudid administered PO per MD orders at 1300. At 1400 pt states "pain is 3/10".

If the fall results in an open wound then you either say you did whatever the doctor ordered (wound cleaned with NS, dry dressing applied per MD orders) , if it didn't fall on you to do the treatment then just chart that the bandage is intact.

Bed is in low position and call bell within reach at all times"

I had a clinical professor that would make us write narratives for each patient we had in clinical and she told us to always end them with "call bell within reach" no matter what. I'm glad you mentioned it.

ACNP-Ray

ACNP-Ray

35 Posts

"Resident on ABO for UTI. Resident has no c/o pain at this time, no c/o frequency or urgency. Vital signs WNL. No adverse effects from ABO noted at this time. Will continue to monitor."

.

That "Vital signs WNL" will get you in a lot of trouble should you ever have to go to court. DONT ever chart that. It can be argued that what is normal for a 2 yr old is not normal for a 22 yr old...etc. It doesn't hurt to actually put the vital signs down. Yes it may be double charting but it shows you have actually looked at said vitals and did see they were in fact (ab) normal for that patient.

As far as charting goes get to a point where you can see that patient laying in bed in your mind and hit each point from head to toe on what is happening with the patient, same way you give report to the oncoming shift. If you can visualize your patients you know who has an NG tube and who is on the vent and what those vent settings are and where their IV's are and what gauge they are and when they need changed, etc. It comes with time but I can tell you when your giving report(which in my opinion should read like your notes) going from head to toe is the easiest fastest way of doing it. Then leave the equipment attached to the pt for last or address it depending on where it's attached.

ixchel

Specializes in critical care. 5 Articles; 4,547 Posts

That "Vital signs WNL" will get you in a lot of trouble should you ever have to go to court. DONT ever chart that. It can be argued that what is normal for a 2 yr old is not normal for a 22 yr old...etc. It doesn't hurt to actually put the vital signs down. Yes it may be double charting but it shows you have actually looked at said vitals and did see they were in fact (ab) normal for that patient.

As far as charting goes get to a point where you can see that patient laying in bed in your mind and hit each point from head to toe on what is happening with the patient, same way you give report to the oncoming shift. If you can visualize your patients you know who has an NG tube and who is on the vent and what those vent settings are and where their IV's are and what gauge they are and when they need changed, etc. It comes with time but I can tell you when your giving report(which in my opinion should read like your notes) going from head to toe is the easiest fastest way of doing it. Then leave the equipment attached to the pt for last or address it depending on where it's attached.

Well that's silly. The medical/nursing professions have established normal limits for vital signs that are age specific. We can also see through charting that a patient's baseline may very well be established at different rates, at which point it might be reasonable to put "Patient vitals continue to be WNL for patient's established baseline." At that point, I might add, "detailed vitals listed in (whatever you call the section where you chart vitals in your charting system)". Hospitals may have their own defined parameters for WNL, which I feel should be reasonable to chart.

(Not arguing with you, of course. Arguing with how silly and useless lawyers can be.)