This site has been very helpful, thank you so much!!! Thank you very much!!!!! Such a huge help! No pain or bladder tenderness reported. There’s a dilemma together with your website in chrome, and you may want to check this The browser will be the market leader and a huge component of other people will omit your great writing because of this issue. Thank you for creating this website, very good sample! You would think it would be a simple thing to find someones sample notes but apparently not so much. Thank you so much. Thanks this is the best I have seen thus far. Aside from client’s record, ward, unit and departmental meetings should be documented as evidence for important decisions taken. With academic EMRs such as Lippincott's DocuCare, nursing students will be able to learn early in their education the ins and outs of proper medical documentation. – Be based on fact, correct and consistent. Do you have a chapter in your Fundamentals Book that gives you examples of documentation. It is a great help for many nurses who are looking for improving their nursing notes. Client’s records may be reviewed to determine if a particular health institution is meeting its stated standards. RLL wet, all other breath sounds clear. The documentation presented herein is provided for educational and informational purposes only. No distention. Good documentation is an important part of improving both patient care and nursing practice. THANKS FOR SHARING. Pulse rate 76. ( Log Out /  7. 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. All members of a healthcare team share information through documentation and reporting. A record is a written or computer –based communication intended to convey information to others. 5. No accessory muscles used. 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. 4. Nursing Documentation: Nursing Documentation Examples. As an instrument of continuous client care and as legal document, the client record should contain all pertinent assessment, planning, intervention and evaluation for the client. This is a FAB post! Here are some good tips to follow when charting: Do's . Pain noted at 5 on the number scale at incision site and radiating to right side. Midline and 2 groin incisions at top of each leg clean, dry and well approximated with derma bond. God Bless! your patients. awesome notes, i am a brand new nurse and this are the best notes i have ever seen thanks a lot. Nursing documentation and it component Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. Documentation is the record of your nursing care. 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Second semester nursing student Adult Health I.Thanks for sharing. Speaking of templates, you can easily find numerous templates related to the practice of health care, such as the Health History Questionnaire and the Patient Satisfaction Survey. Posted Dec 17, 2006. Rate 20, even, unlabored respirations. No pain, urgency, frequency or tenderness with voiding reported. I have been searching everywhere online for this kind of information for my assessments and I have finally found what I need! as they help to clarify actions. Narrative method of documentation – Loss of consciousness Nurses Nursing. PRN acetaminophen administered with pain decreased to a 3 with 30 minutes. I am a new nursing student and you just helped me tons!! Thank you . In summary, documentation is a skill to be This IS an EXCELLENT REVIEWsite. 1 Likes. Dressing clean, dry, intact and reinforced with . THANK YOU SO MUCH for posting assessment documentation examples. Tonight, I got my assessment returned and told my nursing notes “suck”. Documentation encompasses every conceivable form of recordable patient data and information, from vital signs to medication administration records to narrative nursing notes. keccefkeddcg. I’m also a very new nurse and this gave me great insite on the nursing assessment process other than what was taught to us for such short amount of time. 2. This is the information that we can gather using our 5 senses. Scenario #1 Mr. Ron Brown is a 71 year old gentleman with Type 1 diabetes admitted to hospital for treatment of an ulcer on Soft stool at approx 10:00 after administration of Ducolax suppository. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally. Skin pink, cool and dry. Thanks a lot. List 3 legal aspects of charting. And I am looking for a good falls assessment nursing report. No  BM since the day before operation (3/4/08). A ward manager should be highly educated, intelligent, competent, and assertive. . No bladder distention reported. much of the content was similar to test content. The quality of nursing documentation has consistently been found to be failing to meet recommended standards. 4. I believe she has some too. Nice and solid examples. Pain noted at 6 on the number scale. Thanks again. this is absolutley awesome information on documentation thank you very much, I’m a fresh graduate nurse this is really helpfull for me not being bully by other nurses for my charting. Order for dressing change TID. Methods of Documentation – Examples Examples of four methods of documentation are included in this section. Bowel sounds x 4. Gait weak. – Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’. Thanks. Speech clear. To find out more about the specific documentation standards where you practice, contact your state board of nursing. Nothing comes close to it. Temperature is a perfect example of objective data. I realized I wanted to share this though, because there are no examples anywhere. This enables the manager to keep track of supplies. Thanks sooo much really a great help in my final year of nursing. Posture erect. Respirations 4. It help my poor documentation skill. Thank you so much your assessment note has helped me tremendously! 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. 3. Documentation and reporting of the client’s condition require adherence to the highest standards of confidentiality. See more ideas about nursing documentation, nurse, nursing students. Nursing Documentation: Remember the old saying, “if it wasn’t documented, it wasn’t done.” The purpose of the medical record is to provide a clear and accurate picture of the patient while under the care of the healthcare team (Campos, 2009). Abdominal incision site dressed with approx. I received some tips from my husband (an ICU nurse). Nursing documentation… Thank you for sharing this information. Catheter insertion site found with dried sanguineous urine around meatus. Nursing documentation, such as patient care documents, assessments of processes, and outcome measures across organizational settings, serve to monitor performance of health care practitioners’ and the health care facility’s compliance with standards governing the profession and PRN Oxycodone pain medication administered with pain decrease to 3 within 30 minutes. This site is the most helpful I have seen! Services are to be ; Rendered in accordance to the licensing standards and criteria of the Virginia Board of Nursing. A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Thanks for giving permission to print coz i have to read this over and over to prepare myself for documentation once i get a job. Nursing record systems: Effects on nursing practice and healthcare outcomes. Im a new nurse and this will really help me write better nurses notes , WHERE WERE YOU WHEN I WAS IN SCHOOL!!!!!! It’s awesome. VickyRN, MSN, DNP, RN. If anyone knows of any please let me know. No other skin lesions or breakdown found. Anne Young, R.N. Grips, flexion, extension strong bilaterally. A narrative would you indicate the important stats from your shift. The amount/type of document required may vary depending upon payer requirements and good clinical practice. ( Log Out /  Braden score- 20. GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING The temperature of a person can be gathered using a thermometer. Am a new nurse and this is of great help to me. THIS IS A GREAT EXAMPLE OF QUALITY NURSING DOCUMENTATION. Breath sounds clear in all areas. 22 gauge LFA S/L, insertion date 6/1/08. Thanks a million for all of this infomation, greatly appreciate it. Client record is a formal, legal document that provides evidence of client care. In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional. Other examples of objective data: 1. I am a third year nursing student and going into the last practicum of nine weeks. Pain medication administered and pain noted at 3 on same scale 30 minutes later. I’ve been in clinicals just a couple of weeks. S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas. PRN Oxycodone pain medication administered with no relief within 30 minutes. Performed by a Virginia licensed Registered Nurse Nursing documentation frequently reflects the most crucial parts of the medical record. Reported voiding x 2 this morning. 4 inches NuGauze (both superiorly and inferiorly), covered with (2) 4×4, tapped, then covered with binder. Yes, this was hard for me in school too. Pulse rate 72. O b/p 160/95, grimacing face, HR 112, A Pain r/t s/p op aeb grimacing and complaints of pain 9/10. Discuss the purposes of documentation. – Identify problems that have arisen and the action taken to rectify’ (correct or put right). For effective ward management, he/she should combine his/her professional as well as managerial roles in the performance of his/her duties. No other tubes, drains, or Foley. By Ali Muhammad Goniri RN, RM, DNE, BNSC, PGDE. Braden score- 17. Patient not observed OOB. Thank you so much! Good and effective documentation is: Accurate; Factual; Complete; Timely; Organized; … 6. Thank you so much. Cap refillS1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas. 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