Y khoa, y dược - Chapter 4: Nurse note documentation

Chapter 4Nurse Note DocumentationLevel 1© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 4 ContentLO 4.1 Nurse Note ComponentsLO 4.2 Documenting a Nurse Note – Level 1LO 4.3 Chief ComplaintsLO 4.4 Vitals (Vital Signs)LO 4.5 Exam (Physical Assessment)LO 4.1 NURSE NOTE COMPONENTSLO 4.1 Nurse Note ComponentsNursing DocumentationFacilitated by Charting by Exception (CBE)EHRs provide for rapid access to patient informationNurse NoteArea of chart for nursing documentationLO 4.1 Nurse Note ComponentsSOAPIERS = SubjectiveO = ObjectiveA = AssessmentP = PlanI = InterventionE = EvaluationR = Revision/resolutionLO 4.2 DOCUMENTING A NURSE NOTELO 4.2 Documenting a Nurse NoteComponents of SpringChart Nurse Note CC (Chief Complaint), Vitals, Exam (Physical Assessment)Dx (NANDA-I/Diagnosis)NOC (Nursing Outcomes Classification)NIC (Nursing Interventions Classification)Test (Tests)Proc (Procedures)TeachingEvaluationReassess (Reassessment)LO 4.2 Documenting a Nurse NoteDocumentation methodsPop-up textCopy previous notesTypeLO 4.3 CHIEF COMPLAINTSLO 4.3 Chief ComplaintsChief ComplaintIssue that prompted patient to seek careSubjectiveShould be documented in patient’s words as quoteLO 4.4 VITALS (VITAL SIGNS)LO 4.4 Vitals (Vital Signs)Traditional vital signsTemperatureBlood pressurePulseRespirationsOther measurements included by SpringChartsHeightWeight Body mass index (BMI)Body fat percentageLO 4.4 Vitals (Vital Signs)VitalsObjective measurementsMay add three additional measurements such as:Pulse oximeterPain scaleHeight of fundus in pregnant womenLO 4.4 Vitals (Vital Signs)Vitals graphsBlood pressureHeightWeightBMIIncludes children’s growth chartsLO 4.5 EXAM (PHYSICAL ASSESSMENT)LO 4.5 Exam (Physical Assessment)Physical assessmentCharting by Exception (CBE)May indicate normal systems – must know facility definition of “normal”Abnormal findings require additional detailSign and LockUpon completion of documentation in Nurse Note