4-1 chapter 4 nurse note documentation level 1 © 2012 the mcgraw-hill companies, inc. all rights...
TRANSCRIPT
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Chapter 4
Nurse Note DocumentationLevel 1
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
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Chapter 4 Content
LO 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)
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LO 4.1 NURSE NOTE COMPONENTS
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LO 4.1 Nurse Note Components
• Nursing Documentation– Facilitated by Charting by Exception (CBE)– EHRs provide for rapid access to patient
information
• Nurse Note– Area of chart for nursing documentation
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LO 4.1 Nurse Note Components
• SOAPIERS = SubjectiveO = ObjectiveA = AssessmentP = PlanI = InterventionE = EvaluationR = Revision/resolution
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LO 4.2 DOCUMENTING A NURSE NOTE
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LO 4.2 Documenting a Nurse Note• Components 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)– Teaching– Evaluation– Reassess (Reassessment)
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LO 4.2 Documenting a Nurse Note
• Documentation methods– Pop-up text– Copy previous notes– Type
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LO 4.3 CHIEF COMPLAINTS
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LO 4.3 Chief Complaints
• Chief Complaint– Issue that prompted patient to seek care– Subjective– Should be documented in patient’s words as
quote
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LO 4.4 VITALS (VITAL SIGNS)
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LO 4.4 Vitals (Vital Signs)
• Traditional vital signs– Temperature– Blood pressure– Pulse– Respirations
• Other measurements included by SpringCharts– Height– Weight – Body mass index (BMI)– Body fat percentage
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LO 4.4 Vitals (Vital Signs)
• Vitals– Objective measurements– May add three additional measurements such as:• Pulse oximeter• Pain scale• Height of fundus in pregnant women
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LO 4.4 Vitals (Vital Signs)
• Vitals graphs– Blood pressure– Height– Weight– BMI• Includes children’s growth charts
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LO 4.5 EXAM (PHYSICAL ASSESSMENT)
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LO 4.5 Exam (Physical Assessment)
• Physical assessment– Charting by Exception (CBE)• May indicate normal systems – must know facility
definition of “normal”• Abnormal findings require additional detail
• Sign and Lock– Upon completion of documentation in Nurse Note