wcnurse
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O/A all body systems means just what it says. to write this means that you have assessed all body systems. of course you will document any abnormal finding but one should also be sure to document any specific order whether there is an abnormalty or not. such as, If the 485 specifically states "assess for signs and symptoms of UTI, make sure to document, no s/s UTI, no burning urgency, urine clear without odor.
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look at the 485, then under your skilled nurse note, you address everything thats listed. for example... O/A all body systems. vss. wound care per order, no s/s of infection at wound site. meds checked and appropriate for compliance. No s/s increase or decrease glycemia. Pt. voices pain level at a 2 on 1-10 scale.
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we have case conference every wednesday morning regarding all patients with upcoming d/c or recert.