I realized I wanted to share this though, because there are no examples anywhere. You would think it would be a simple thing to find someones sample notes but apparently not so much. Use direct quotes for subjective assessment. ( Log Out /  Information from record may assist healthcare planner to identified institutional needs, such as over utilized and underutilized hospital services. Wife has arthritis and back problems, so in-home assistance may be needed for a period of time. 4. Department of Medical Assistance Services ; October 6, 2009 ; 2 Skilled Nursing Services. Too standardized for me ! No accessory muscles used. 3. To find out more about the specific documentation standards where you practice, contact your state board of nursing. No other tubes, drains, or Foley. This is really a great site for getting info on how to do nursing documentation. This helped me a lot a lot and a lot. Pt concerned about pet (Beauty) and not being able to take her on long walks which they both enjoy. This IS an EXCELLENT REVIEWsite. Generally nurses communicate with their Assessment                                                                 Thursday                                           Friday, Usual pattern/ changes since hospitalized, Feelings or concerns r/t hospitalization, illness. Proper Documentation Example #1: 03/21/14 0800 Mrs. GH alert, awake, and oriented to person and situation but is confused as to time and place. Aid hospital management in planning. What a relief! In each of the examples, the following is printed at the end “Nurse’s signature, designation”, but ensure that you sign your name and insert your specific designation. By Ali Muhammad Goniri RN, RM, DNE, BNSC, PGDE. No pain, urgency, frequency or tenderness with voiding reported. She is able to state her name and that she is in the nursing home but states that it is afternoon and that it is 1990. C. – Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’. Thank you so much. Yes, this was hard for me in school too. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. Performed by a Virginia licensed Registered Nurse Dressing found clean and intact with scant amount of sanguiness drainage during assessment. Family/ support systems. Respirations 4. Nurses are responsible for accurate, complete and timely documentation and reporting. FUNNY QUOTES FROM REAL A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Affect and facial expression appropriate to situation. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally. Just a thought. psychiatric nursing documentation examples. In summary, documentation is a skill to be Provides evidence for evaluation purposes. Documentation is the record of your nursing care. Three puncture wounds from laparoscopic nephrectomy, well approximated, covered with steri-strips located right medial midline, inferior and superior left lateral abdominal area, no site swelling or redness. Thank you for creating this website, very good sample! God bless. INTRODUCTION It is a fact that accurate record keeping and careful documentation is an essential part of nursing practice and effective communication among nurses vital to the quality of client care. – Be written, wherever possible, with the involvement of the patient,. If anyone knows of any please let me know. Bowel sounds x 4. – Be based on fact, correct and consistent. 4. Discuss the purposes of documentation. This site is the most helpful I have seen! Examples of Nursing Documentation. I am a returning nurse out after the field for over 20 years. If it is meticulous, appropriate and truthful, it supports quality medical care. – Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements’. Documentation and record keeping are vital instruments in the management of nursing services, since the client record may be used to provide evidence in court. your patients. – Identify problems that have arisen and the action taken to rectify’ (correct or put right). I believe she has some too. It is a great help for many nurses who are looking for improving their nursing notes. 5. INTRODUCTION Serves as a vehicle by which different health professionals who interact with a client communicate with each other. Ambulation description. All members of a healthcare team share information through documentation and reporting. Looking for some websites that may have some examples of nursing documentation, charting, or nurses notes. Thanks. Good documentation is a major part of a nurse’s responsibilities at work. See more ideas about nursing documentation, nursing documentation examples, nursing notes. Nurses Nursing. Area cleaned thoroughly. I’m looking for fast guide for medical terminology for RNs, I have to tell you that I must have spent an hour looking for 1/2 of the information you have and found nothing. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes. No other skin lesions or breakdown found. Nursing documentation frequently reflects the most crucial parts of the medical record. Thank you so much! Gait weak. Here are some good tips to follow when charting: Do's . The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. The expert will look at the nursing documentation for clues and evidence that the care rendered wasn't consistent with appropriate nursing care in order to form an expert opinion. Some examples of direct skilled nursing services are IV feeding (must meet criteria), IV meds, suctioning, tracheostomy care, rehabilitation nursing procedures, ulcer care, tube feedings, care for surgical wounds, and diabetes management with injections. Reported last BM was formed 5/31/08. Thanks. Catheter insertion site found with dried sanguineous urine around meatus. Pt transferred from rehab facility and expects to go back to another facility prior to going back home where wife is caregiver. Grips, flexion, extension strong bilaterally. Nursing documentation must reflect the need for the continuation of skilled care. Abdominal sagittal midline well approximated incision with packed wound at inferior and superior ends, both approx 1 cm in circumference and 11-12 mm in depth, no site redness or swelling, scant sanguiness drainage. Thanks! It is either a measurement or an observation. Speech clear. Thank you so much! so THANK YOU. Change ). Cool post. colleagues, clients and other healthcare professionals through discussion, reports and records. Pt reported reduced pain and was able to get rest during the night. It has helped me. A clinical record, also called a chart. Soft stool at approx 10:00 after administration of Ducolax suppository. maybe like ensuring and maintaining a safe environment and monitoring for any signs or symptoms of withdrawal or any distress? best things ,its very use full us , thank you, This is FABULOUS! You should look at Tired Student Nurse. No pain or bladder tenderness reported. When nurses perform care, they must be accountable for their action as documentation connotes accountability. The quality of nursing documentation is an important issue for nurses both nationally and internationally. God Bless. A,B,C,E. Nursing record systems: Effects on nursing practice and healthcare outcomes. Oriented x4. Am a new nurse and this is of great help to me. A ward manager should be highly educated, intelligent, competent, and assertive. The information in this type of documents must be integrated for the meaning in a nursing election. In addition, records and reports assist nurse managers to evaluate staff performance. This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses from achieving good documentation standards. This makes sure that the next person has an organized information about the patients in order to properly care for them in his/her shift. your sample nclex questions helped me out alot too in my nursing classes. Tonight, I got my assessment returned and told my nursing notes “suck”. Patients report of consistent lack of pain relief reported to his nurse. Pain noted at 5 on the number scale at incision site and radiating to right side. this is absolutley awesome information on documentation thank you very much Mary says: October 17, 2012 at 3:51 pm C. Be certain that entry is factual even when opinions are used. . No bladder distention reported. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING Cap refillS1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas. Please advise, thank you. Thank you so, so much!!! – Be written clearly and in such a way that the text cannot be erased’ (rubbed out or obliterated). Cap refill. 2. The amount/type of document required may vary depending upon payer requirements and good clinical practice. 4. This site has been very helpful, thank you so much!!! Methods of Documentation – Examples Examples of four methods of documentation are included in this section. It is a fact that accurate record keeping and careful documentation is an essential part of nursing practice and effective communication among nurses vital to the quality of client care. It would be better if it was more interactive though. Patient not observed OOB. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally. Serves as an audit tool. Other healthcare professionals through discussion, reports and records court of law will tend assume... To keep track of supplies them in his/her shift are used where the defence! Of ward rosters, protocol of care, they must be accountable for action. Scant amt of serosanguiness drainage on the number scale at incision site and radiating to side. 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Data and information, from vital signs to medication administration records to narrative nursing notes Templates examples.