Nursing Documentation

No. Stable is a broad term. Unfortunately if the pt was truly just "stable" why is he an inpatient? = denial claim from ins

First, I avoid using "I" (first person tense) in my notes.

My general note will go something like this:

Pt's diagnosis/biggest issues (Bowel Obstruction, Sepsis, s/p bowel resection)

My actions for the day: Pt on continuous vital sign monitoring throughout shift. Repositioned q 2 hours and PRN. NGT reinserted in R nare after displacement. Tube taped at 18cm, placement confirmed via air injection and aspiration of contents. See flowsheet for vital signs, detailed assessments, and I&O. See MAR for meds/treatments given.

Brief evaluation: Vital Signs stable throughout shift. Afebrile. HR 110-130. BP maintained with MAPs of 60-70. Sinus rhythm, no ectopy, no murmur. Extremities warm, pink and well perfused. Cap refill 2 second, +2 equal pulses b/l. Lungs clear and equal b/l on 3 L O2 via nasal cannula. B/l bases diminished. SpO2 maintained between 94-97%. Incentive spirometry performed q hour with personal best of 550 mL. No cough, secretions, or increased work of breathing. Abdomen soft, tender, non distended. Girth 58cm across umbilicus. NGT secured in R nare, draining green, bilious liquid. No bowel sounds heard X4 quadrants. No flatus passed. Voiding clear yellow urine. Midline abd incision is clean, dry and intact. PERRLA, moves all extremities, alert and oriented X3. PIV access in R hand. IV patent and infusing without pain. Site free of complications, dressing intact.

Plan for next shift: Any labs due, procedures in the am, specific questions that need to be addressed, changes in medications, etc.

I understand that your facility may require less documentation on your patient's then my unit. But since you are new, I'd suggest being more detailed then you have to be at first, until you learn what's expected of you. Practice makes perfect, so ask another nurse to review your note and give you suggestions. Welcome to nursing!

I'm guessing you have paper documentation. I