Private Duty Narrative note ideas for peds

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Hey there!! I'm new to private duty nsg, not a new nurse. Just looking for narrative note ideas for my peds pt, we go to school 5 days a week. He requires skilled nsg services d/t DX Spina Bifida, attn to urostomy, attn to colostomy and congenital anomaly NOS. even tho he was born w/ Spina Bifida he's ambulatory. He is a very independent young man! I basically check him q2h and PRNs, monitor and change as necessary. Any help with charting would be appreciated! He is a Medicaid case.

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Specializes in NICU, ICU, PICU, Academia.

Just write what you do and your assessment of his condition.

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Specializes in Complex pedi to LTC/SA & now a manager.

What do other nurses document? What is your company protocol? What does your clinical nurse manager recommend?

You write your assessment, observation, document interventions, treatment .& medication. Most also need I& O approximations. Plus documentation of progress towards goal in the 485. School hours are paid by the board of education not Medicaid FYI.

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

Also, need to determine if hourly reporting is necessary -- all of my cases require hourly notes to justify constant nursing care (versus "visits").

So even if I don't have to "do" anything in a particular hour, I still write an observational note regarding what the patient is doing/not doing (sleeping, eating, playing, whatever), no s/s of distress, brief dry, etc.

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