I'm sharing these examples of a head to toe assessment with negative and positive findings. Please post any suggestions on what you think is important to add.
NEGATIVE FINDINGS...
Is this a good example for discharge documentation?
I met with resident and explained discharge instructions and medication list. Resident verbalized understanding. Call received from daughter...
Is this a good progress note for a patient transfer to a Hospital? Any suggestions...
CNA reported to me that the resident had three episodes of coffee ground emesis this morning. The resident...
Is this a good example for daily Progress Notes? Any suggestions welcome.
Nurse's Notes
The resident is resting comfortably in bed, with fall precautions properly implemented. The call...
Is this a good example for documenting a new admission?
New Admission Notes: Resident NAME is a ____-year-old female/male admitted to Room _____ from WHAT HOSPITAL? via stretcher, accompanied by...