Nursing Information System

This is software programs allow nurses to record/document nursing actions in the

patients electronic records.
It collect, transmits, organize, format, print and display information that you can use to
help make a decision in either software or hardware, but they dont make decisions for
you.
Nursing
Nursing is an integral part of the health care system, and as such encompasses the
promotion of health, prevention of illness, and care of physically ill, mentally ill, and
disabled people of all ages, in all health care and other community settings.
Information
The communication or reception/purpose of knowledge or intelligence.
knowledge obtained from investigation, study, or instruction
!"T#, $!T!
System
a group of interacting bodies under the influence of related forces
an organization forming a network especially for distributing something or serving a
common purpose
an organized or established procedure
method% techni&ue% procedure
Documentation
' $efined as(
Written documentation
The interaction between and among health professionals, clients, their families, and
health care organizations.
The administration of tests, procedures, treatments, and client education.
The results of, or clients response to, diagnostic tests and interventions. )age *+ T
Professional responsibility of all health care practitioners, documentation provides written
evidence of the practitioners accountability to the client, the institution, the profession, and
society.
Communication
!ccurate data needed to plan the clients care and to ensure continuity of care.
! method of communication among the health care team member responsible for the
clients care
,ritten evidence of those things done for the client, the clients response, and any
revisions made in the plan of care.
-vidence of compliance with professional practice standards.
! resource for review, audit, reimbursement, education, and research.
! written legal record to protect the client, institution, and practitioner.
Education
.ealth care students can use the medical records as a tool to learn about the disease
processes, complications, medical and nursing diagnosis and interventions.
/. ace sheet
a. $emographic data
' Name
' "lients identifying number
' $ate of birth
' !ddress
' Telephone number
' $ate of birth, place of birth, se0, race, marital status, religion
' Name and address of closest relative
' ## number
' !dmission date and hour
' Type of admission
a. -mergency ' an unforeseen combination of circumstances or the resulting state
that calls for immediate action % danger
b. )alliative ' to reduce the violence of 1a disease2% also ( to ease 1symptoms2
without curing the underlying disease
c. -lective ' permitting a choice ( 3)TI3N!4 5an elective course in school5 b (
beneficial to the patient but not essential for survival 5elective surgery
6. 7edical history and physical e0amination
a. "lients description of chief complain
b. )resent and past illnesses, personal and family histories
c. 8eview of systems as elicited by the physician 1cephalocaudal assessment2
-.g history of present illness
)ast illness
amily history
"hildhood history
7aternal history
+. Nursing admission assessment
' $ata from interview and physical assessment performed by the nurse.
9. )hysicians orders
' )hysicians written or verbal order to admit, to direct clients diagnostic and
therapeutic course, and to discharge.
:. "onsultation report
' indings of a physician whose opinion or advice is re&uested by another physician
for evaluation and treatment of a client.
;. )hysicians progress notes
' )rovides a pertinent, chronologic report of the clients course in the hospital and
reflects any change in condition and response to treatment. 7ay also contain notes
by other member of the health care team.
*. 4aboratory reports
' 8esults from laboratory tests ordered by the physician.
<. 8adiology reports
' 8adiologists interpretation of radiologic and fluoroscopic diagnostics services
=. Nuclear medicine
' $escribes diagnostic studies and therapeutic procedures performed using
radiopharmaceutical agents
/>. ?raphic sheet
' @arious client parameters, most commonly% T,),8 and A). 7ay also include weight,
diet, IB3
//. "lients care plan
' Treatment plan including nursing diagnose or problem list, client goals, nursing
actions, and evaluation
/6. Nurses notes
' $etails care and treatments provided clients response to care and treatments,
achievement of e0pected outcomes that do not duplicate information on low #heet
1if used2.
/+. low sheet
' !ll routine interventions that can be indicated by a check mark or other simple
descriptor.
/9. 7edication administration
' "ontains all medications administered orally, topically, by inCection, inhalation, and
infusion in one place% includes date, time, dosage, route of administration, and name
of professional administering the drug. 8outine, )8N, and single dose orders
generally have separate sections.
/:. "onsent forms
' !dmission( gives the institution and physician permission to treat
' #urgical( e0plains the reason for and nature of the treatment, the risks,
complications, and alternate forms of treatment, no treatment, conse&uences of
treatment or procedure. #ometimes surgical and anesthesia consents are separate so
that responsibility is placed appropriately.
' Alood Transfusion( gives specific permission to administer blood or blood products.
' 3ther( procedure specific consent forms, participate in research proCect,
photography.
/;. "lient education record
' $escribes the nurses teaching to the client, family, or other caregiver and the
learners response.
/*. .ealth care team record
' Dsed by respiratory therapist, physical therapy, dietary when physicians progress
are used only by physicians
/<. Nursing discharge summary
' "ontains brief summary of care provided, medications, teaching, and other
instructions 1e.g., return appointment, referrals2, discharge status, and mode of
discharge.
/=. $ischarge summary
' 8eview of events describing the clients illness, investigation, treatment, response,
and condition at discharge.
' 7 E medication
- E -nvironment and e0ercise
T E Treatment
. E .ealth teaching
3 E 3bserve strict follow up check up
$ E $iet
6>. !dvance directives
' 4iving will and durable power of attorney
$ocumentation is owned by the hospital
#ubpoena ducen tecum
Research
.istory
Legal and practice standards
The clients medical record is a legal document, and in the case of a lawsuit, it is the
record that serves as the description of e0actly what happened to a client.
)roof of significant event
Issues(
a. 4egible and neat writing
b. "orrect spelling and grammar
c. Dse of authorized abbreviations
d. $ate and time for each entry
e. !ccurate, factual, time'se&uenced, descriptive notations
Types(
/. Informed consent
' It is a competent clients ability to make health care decisions based on full
disclosure. If the benefits, risks, and potential conse&uences of a recommended
treatment plan and of alternative treatments, including no treatment, the clients
voluntary agree to the treatment.
a. 3rally
b. ,riting
' "haracteristics of a valid consent
/. )roper e0planation of the procedure
6. -0planation of possible outcome of the procedure
+. -0planation of alternative treatments and options
9. $escription of the benefits derived from said treatment
:. -0planation of risks and cost
;. -0planation is understood by the patient. Translation if needed
*. The patient is given the chance to ask &uestions about the procedure
<. The opportunity to refuse recommended treatment or procedure
=. 8ight to withdraw / cancel prior consent if re&uested by the patient
/>. 7entally and physically able to give their personal consent.
"onsent involves the presence of two elements, namely(
a. @oluntary act E independent will
b. )ersonal act E ones own hand writing or signature in the consent form
-0ception(
a. 7inors
b. Insane
c. 7entally ill
d. "omatose
6. !dvance directives
c. 4iving will and durable power of attorney for health care is written instructions
about an individuals health care preferences regarding life sustaining measures
that guide family members and health care professionals as to those treatment
options that should or should not be considered in the event that the individual is
unable to decide.
+. #tate nursing practice acts
a. In an attempt to recognize and control the practice of nursing, nursing practice
acts, on a state by state basis, establish guidelines to ensure safe practice and to
demonstrate accountability to society.
Reimbursement
' It is use to determine the amount of a facility receives for care provider.
''''''''''''''''''''''''''''''''''''''''7idterm''''''''''''''''''''''''''''''''''''''''''''''''''''
General documentation guidelines
/. -nsure that you have the correct client record or chart and that the clients name and
identifying information are on every page of the record.
6. $ocument as soon as the client encounter is concluded to ensure accurate recall of data
1follow institutional guidelines2.
+. $ate and tile each entry.
9. #ign each entry with tour full legal name and with your professional credentials, or per
your institutional policy.
:. #ign each entry with tour full legal name and with your professional credentials, or per
your institutional policy.
;. $o not leave space between entries.
*. If an error is made while documenting, use a single line to cross out the error, then date,
time, and sign the correction 1follow institutional guidelines2% erasing, crossing out, or
using correction fluid is not acceptable.
<. Never change another persons entry, even if it is incorrect.
=. The first entry of the shift should be made early 1e.g. at *(+> !.7. for the *'+ shift, as
opposed to //(+> !.7. or /6 ).7.2. "hart at least every 6 hours, or per institutional
policy.
/>. Dse &uotation marks to indicate direct client responses 1e.g. FI feel lousyG2.
//. $ocument in chronologic order% if chronologic order is not used state why.
/6. ,rite legibly.
/+. Dse a permanent ink pen.
/9. $ocument in a complete but concise manner by using phrases and abbreviations as
appropriate.
/:. $ocument all telephone calls that you make or receive that are related to a clients case.
/;. Dse proper abbreviation.
e.g. )T
/. patient
6. protrombine time
+. physical therapy
9. part time
Methods of documentation
/. Narrative charting 1T p. //> ( I p. ;;2
' The traditional method of nursing documentation is a chronologic account written in
paragraphs describing the clients status, interventions, and treatments, and the
clients response to treatments.
' The most fle0ible of all methods and is usable in any clinical setting.
' -.g.
a. ! change in patients condition, such as progression, regression or new
problem.
b. ! patients response to a treatment or medication
c. ! lack of improvement in the patients condition
6. #ource'oriented charting
' It is described as a narrative recording in separate sheets by each member of the
health care team.
+. )roblem'oriented charting
' )roblem'oriented medical record 1)3782 focuses on the clients problem and
employs a structured, logical format.
' "omponents(
a. $atabase E assessment data
b. )roblem list E clients problems numbered according to when identified.
c. Initial plan E outline of goals, e0pected outcomes, learning needs and further
data, if needed.
d. )rogress notes E charting based on the #3!), #3!)I-8, or #3!)I-8
format.
i. # ( what the clients or family member states
ii. 3 ( what is observed
iii. ! ( conclusion reached on the basis of date formulated as client
problem or nursing diagnosis.
iv. ) ( e0pected outcome or action to be taken
v. I ( measure taken to achieve e0pected outcomes
vi. - ( analyze effectiveness of interventions
vii. 8 ( revision 1changes in original plan2
9. )I- charting
' The key components of this system are assessment flow sheets, nurses progress
notes, and an integrated plan of care.
:. ocus charting
' It is a documentation method that uses a column format to chart data, action, and
response 1$!82.
a. "hart data E a sign and symptoms
b. !ction E an acute change in the clients condition.
c. 8esponse E a special need
;. "harting by e0emption
' It is a documentation method using standardized protocols stating what the e0pected
course of the illness is and only significant findings are documented in a narrative
form. It assumes that client care needs are routine and predictable and that the
clients responses and outcomes are also routine and predictable.
*. "omputerized charting
' Issues to be addressed when considering computerized client records include data
standards, vocabularies, security, legal issues, and costs.
' $isadvantages include all the problems inherent in computerized storage of records,
such as maintaining confidentiality, controlling who has access to which data, and
correcting errors.
<. "ritical pathway 1care map2
' The overall goal for critical pathways is to improve the &uality and efficiency of
client care. The se&uence and timing of interdisciplinary activities is established
including assessments, consultations, diagnostic tests, nutrition, medications,
activities, treatments, therapeutics, education, and discharge planning. ,hile nursing
diagnoses as such are not generally included in a critical pathway, a nurse may
identify nursing diagnoses and interventions for a specific client.
' .ealth care facilities develop their own critical pathways. !n interdisciplinary tem
including nurses, physicians, dietary, rehabilitative services, social services, and
others when needed, develop the critical pathway through consensus about the
management of the identified case situation. This is a time consuming task% but once
written, a critical pathway can be revised based on a review f the variances.
Forms for recording data
' !ll of these forms are designed to facilitate record keeping, minimize duplication of
effort and ensure &uick and easy access to information.
/. Harde0
' It is the summary worksheet reference of basic client care information traditionally
not part of the medical record. ! concise client care source, karde0 is used as a
reference throughout the shift and during change of shift reports.
"lients data
Name
!ge
7arital status
8eligious preference
)hysician
amily contact with phone number
7edical diagnoses( listed by priority
Nursing diagnoses( listed by priority
!llergies
7edical orders(
$iet
7edication
I@ therapy
Treatments diagnostic tests and procedures 1inclusive of dates and results2
"onsultations
$N8 orders
!ctivities permitted (
unctional limitations
!ssistance needed in activities of daily living
#afety precautions
6. low sheet
' low sheets have columns for recording dates and times for assessments and
intervention information, making it easy to track changes in the clients condition.
' "lient teaching, use of special e&uipment and I@ therapy may also be included.
' #upplemental documents
+. Nurses progress notes
' It is used to document the clients condition, problems, and complaints%
interventions% the clients response to interventions% and achievement of outcomes.
' In any type of documentation system
9. $ischarge summary
' The discharge summary highlights the clients illness and course of care.
' Narrative form
' It includes(
The clients status at admission and discharge
! brief summary of the clients care
Intervention and education outcomes
8esolved problems and continuing care needs for unresolved problems,
inclusive of referrals
"lient instructions regarding medications, diet, food'drug interactions,
activity, treatments, follow'up and other special needs.
Reporting
' It is the verbal communication of date regarding the clients health status needs,
treatment, outcomes, and responses.
' "lient information reported to other health care providers should be documented in
the clients record.
' Information for shift report
a. "lient name, room and bed, age, and gender
b. )hysician, admission date and diagnosis, and any surgery
c. $iagnosis tests or treatments performed in the past 69 hours% results, if
available
d. ?eneral status, any significant change in condition
e. New or changed physicians order
f. Nursing diagnoses and suggested nursing orders
g. -valuation of nursing interventions
h. Intravenous fluid amounts last prn meds
i. "oncerns about the clients
/. #ummary report
' 3utline information pertinent to the clients needs as identified by the nursing.
' !lmost same as endorsing charting
6. ,alking rounds
' It is reporting method used when the members of the care team walk to each other
and with the client.
a. Nursing rounds
b. Instructor E student rounds
c. )hysician rounds
d. 7ultidisciplinary
+. Telephone reports and orders
' Types(
a. 8eport transfers
b. "ommunicate referrals
c. 3btain client data 1laboratory results2
d. #olve problems
e. Informed clients family members regarding a change in the clients
condition.
' Things to remember(
a. Identify herself
b. ,hom you are calling
c. 8eason of the call
d. $ate and time the call was placed
e. The client data the reported by the nurse
f. The name of the person with whom the nurse spoke
g. ,hether an order was obtained should be recorded accurately in the clients
medical record.
h. 8epeat the order that has been ordered
i. 4et the call witness by another nurse
C. ,hen signing, start with T.3. then the name of the doctor, then the name of
the nurse who made/received the call and the name of the nurse who witness
the call. Then signI
k. 7ake sure that the physician who made the order will counter sign the
telephone order within 69 hours or depends upon the institutional policy.
l. Include in the nurses notes that you had a telephone order but not the
content of the order.
9. Incident reports
' Dsed to reports any unusual occurrence or accident in the delivery of client care,
such as falls or medication error.
' The incident report serves two functions(
a. It informs the facilitys administration of the incident, thereby allowing risk
management personnel to consider changes that might prevent similar
occurrences in the future.
b. It alerts the facilitys insurance company to a potential claim and the need for
further investigation.
' Hey elements(
a. The date, e0act time, and place the nurse discovered the occurrence should be
recorded.
b. The person involved in the occurrence, including witnesses, should be
identified.
c. The e0act occurrences witnessed by the nurse must be accurately and
obCectively documented% for e0ample, Ffound the client sitting on the floor,
client states thatJ,G rather than Fclient fellG.
d. The e0act details of what happened and the conse&uences for the persons
involved must be recorded in time se&uence.
e. The nurses actions to provide care and the results of the nurses assessment
for inCuries and client complaints should be recorded.
f. The supervision on duty notified and the time and name of the physicians
notified is recorded. If telephone ordered were received from the physician,
these should be documented as previously discussed.
g. The nurse should not record personal opinions, Cudgments, conclusions, or
assumptions about what occurred% point blame% or suggest ways to prevent
similar occurrence
h. The incident report should be forwarded to the designated person as defined
by the facilitys policy.
''''''''''''''''''''''''''''''''''''''''''''''''''Semifinals'''''''''''''''''''''''''''''''''''''''''''''''''''''
Charting
Guidelines for charting procedures
/. ,hat procedure was performed
6. ,hen it was performed
+. ,ho performed it
9. .ow it was performed
:. .ow well the patient tolerated it
;. !dverse reactions to the procedure, if any
7edical administration
/. ollow your facilitys policies and procedures for recording drug orders and
administration.
6. 8ecord the patients full name, medical record number, and allergy information on
each 7!8.
+. Immediately document the drugs name, dose, and route of administration,
fre&uency, the number of doses ordered or the stop date and the administration time
for doses given.
9. ,rite legibly
:. Use only standard abbreviation. ,hen in doubt write out the whole phrase.
;. !fter administering the first dose, sign your full name, licensure status, and initials
in the appropriate space.
*. 8ecord drug administration immediately after each dose is administered so that
another nurse doesnt inadvertently repeat the dose.
<. If you chart by computer, do so right after giving each drug.
=. If a specific assessment parameter must be monitored during administration of a
drug, document this re&uirement in the 7!8
/>. If you didnt give a drug, circle the time and document the reason for the omission.
//. If you suspect that a patients illness, inCury, or death was drug related, report this to
the pharmacy department, they will relay the information to the ood and $rug
!dministration.
p.r.n. meds
/. or eyes, ear, or nose drops, chart the number used as well as the administration
route.
6. or suppositories, chart the type 1rectal, vaginal, or urethral2 and how the patient
tolerated it.
+. or dermal drugs, chart the size and location of the area where you applied the drug
and the condition of the skin or wound.
9. or dermal patches, chart the location of the patch.
:. or I.@., I.7., or subcutaneous medications, charts the dose given and the location of
administration.
$rug abuse or refusal
/. If you discover non'prescribed drugs at the patients bedside. $ocument the type of
medication, the amount of medication, and its color and shape. Then follow
institutional policy.
6. Kou find a supply of prescribed drugs in the patients bedside table. Indication that he
isnt taking each dose. 8ecord the type and amount of medication.
+. Kou notice a sudden change in the patients behavior after he has a visitor, and you
suspect them of giving him opioids or other drugs. $ocument how the patient
appeared before the visitors came and afterward. Notify the doctor immediately and
follow your facilities policy.
9. Kou offer prescribed medications and the patient refuses to take them. $ocument the
refusal, the reason for it 1if he tells you2, and the medication, this precents the refusal
from being misinterpreted as an omission or a medication error on your part.
e.g. patient refused Hetorolac I@, stating that they were too painful as it enters the
vein. $r. "iruCano notified. Hetorolac I@ order discontinued. Tramadol ordered
and given. ollow institutional policy.
8eport any medication abuse or refusal to the doctor. ,hen you do so, document the name of
the doctor and the date and time of notification.
3pioid administration
/. #ign out drug on the appropriate form
6. @erify the amount of drug in the container before giving it.
+. .ave another nurse document your activity and observe you if you must waste or
discard part of an opioid dose.
9. "ount opioids after each shift.
ollow institutional policy.
I.@. therapy
!fter insertion
/. $ate, time, and venipuncture site.
6. -&uipment used such as the type and gauge of the catheter or needle
+. Number of venipuncture attempts made and the type of assistance re&uired.
9. Type, amount, and flow rate of I.@. fluid.
:. "ondition of the I@ site
;. That you flashed the I@ line and what medication you used.
Dpdate your records each time you change the insertion site and the reason why.
a. -0travasation
b. )hlebitis
c. 3cclusion
d. )atient removal
e. 8outine change
T)N
/. Type and location of the central line
6. "ondition and type of dressing applied
+. !ppearance of the administration site
9. ,hy it was discontinued
Alood Transfusion
/. "heck for the label and cross matching by two nurse
a. )atients name
b. )atients medical record number
c. )atients blood group or type
d. )atients and donors 8h factors
e. "ross match data
f. Alood bank identification number
6. $ate and times the transfusion was started and completed
+. Name of the health care professional who verified the information
9. Type and gauge of the catheter used
:. Total amount of the transfusion
;. )atients vita% signs before, during, and after the transfusion and as re&uired by your
facilitys policy
*. Infusion device used, if any, and its flow rate
<. Alood warming unit used, if any.
' If reaction occursI
/. Time and date of the reaction
6. Type and amount of infused blood or blood products
+. Times you started and stopped the transfusion.
9. "linical signs in the order of occurrence
:. )atients vital sign per facility protocols
;. ,hether urine specimens and blood samples were sent to the laboratory for analysis
*. Treatment you give and the patients response to it.
#urgical incision care ( if the nurse will dressed the wound
/. Type of wound care performed
6. ,ounds appearance 1size, color, condition of margins, presence of wound closure
devices and necrotic tissue2% odor, if any% location of drains% and drainage
characteristics 1type, color, consistency and amount2
+. "ondition of skin around drain or wound
9. Type and amount of dressing and whether a pouch was applied
:. !dditional wound care procedures, such as drain management, irrigation, and
packing, or application of a topical medication.
;. .ow the patient tolerate the dressing change
*. Teaching provided to patient
e.g. $ressing removes from right mastectomy incision% / cm sized area of serous
sanguineous drainage on dressing. Incision well appro0imated with staples intact.
#ite cleaned with sterile N## 9G 0 9G sterile dressing applied. Teaching given to patient
regarding dressing change and signs and symptoms of infection.
)acemaker care
/. $ate and time of placement
6. 8eason for placement
+. )acemaker settings and type
9. )atients response
:. )atients 43" and vital signs, including which arm you used to obtain the blood
pressure reading
;. "omplications, such as chest pain and signs of infection
*. Interventions such as L'rays to verify correct electrode placement
<. 7edication that may have been given before or during the procedures.
-.g. patient with temporary transvenous pacemakers in right subclavian vein. .eart rate
;>. 7onitor showing />> M ventricular paced rhythm. -"? obtained. )acemaker sensing
and capturing correctly site without redness or swelling. $ressing dry and intact.
)eritoneal dialysis
' during and after the procedure
/. )atients vital signs per facility protocol
6. !brupt changes in the patients condition and that you notified the doctor
+. !mount and type of dialysate infused and drained and medications added
9. -ffluents characteristics and the assessed negative or positive fluid balance at the end
of each infusion dwell drain cycle
:. )atients daily weight and abdominal girth, noting the time of day and variations in
the weighing and measuring techni&ue
;. )hysical assessment findings
*. luid status
<. -&uipment problems, such as kinked tubing or mechanical malfunction, and your
interventions
=. "ondition of the patients skin at the catheter site
/>. )atients reports of unusual discomfort or pain and your interventions.
//. !ny break in aseptic techni&ue and that you notified the doctor
/6. ,hether the patient or family member performs the peritoneal dialysis procedure.
)atient received e0changes &6h of /:>> ml 9.6: dialysate with :>> units heparin and 6
me& H"l % infused over : min. dwell time /: minute drainage clear, pale yellow fluid.
)atient tolerated procedures without complications or discomfort. 44N catheter site non'
reddened. #ire cleaned and dressed per protocol. )atient weight after dialysis 6>: lb.
)eritoneal 4avage
/. )atients vital signs and symptoms of shock, such as tachycardia, decrease blood
pressure, diaphoresis, dyspnea, and vertigo
6. "ondition of the incision site
+. Type and size of the peritoneal dialysis catheter used
9. Type and amount of solution instilled into the peritoneal cavity
:. !mount and color of the fluid withdrawn from the peritoneal cavity and whether it
flowed freely in and out
;. ,hat specimens were obtained and sent to the laboratory for analysis
*. "omplications that occurred and your interventions.
Thoracic drainage
' if your patient has thoracic drainage, initially record(
/. $ate and time the drainage begun
6. Type of system used
+. !mount of suction applied 1if any2 to the pleural cavity
9. )resence or absence of bubbling or fluctuation in the water'seal chanber
:. !mount and type of drainage
;. )atients respiratory status, including breath sounds
' !t the end of each shift, record(
/. #ow fre&uently you inspected the drainage system
6. )resence or absence of bubbling or fluctuation in the water'seal chamber
+. )atients respiratory status, including breath sounds
9. "ondition of the chest dressings
:. Type, amount, and route of pain medication you gave
;. "omplications and subse&uent interventions.
' 3ngoing documentation should include(
/. !mount of suction applied, if any
6. "olor, consistency, and amount of thoracic drainage in the collection chamber as well
as the time and date of each observation
+. )atient'teaching sessions and activities you taught the patient to perform, such as
coughing and deep breathing e0ercises, sitting upright, and splinting the insertion site
to minimize pain
9. 8ate and &uality of the patients respirations and your auscultation findings
:. "omplications, such as cyanosis, rapid or shallow breathing, subcutaneous
emphysema, chest pain, it e0cessive bleeding, and the time and date you notified the
doctor
;. $ressing changes and the patients skin condition at the chest tube site.
8ight anterior chest tube intact to 6> cm .63 suction. />> ml bright red bloody drainage
noted since +(>> am, co air leak noted, O water chamber fluctuation. "hest tube site
dressing dry and intact, no crepitus palpated. 8espiratory assessment unchanged as per
flow sheet.
"ardiac monitoring
' or the patient receiving cardiac monitoring, include in your notes(
/. $ate and time the monitoring begun
6. 7onitoring leads used
+. 8hythm strip readings labeled with the patients name and room number and the date
and time
9. "hanges in the patients condition
!t /6(9: am monitoring showing #T ".8 :> with multifocal )@"s. )atient complaining
of #3A and palpitations, 36 6 4 via nasal cannula placed. @) /*</ =;. -"? done. $r.
"iruCano notified and he administered 4apressor : mg I@ at /6(:>. Alood drawn for
serum electrolytes and sent to laboratory. 7onitor presently showing N#8 with
multifocal )@"s. )atient denies #3A, chest pain, t palpitations a present.
"hest physiotherapy
' ,henever you perform chest physiotherapy, document(
/. $ate and time of your interventions
6. )atients positions for secretion drainage and how long he remains in each
+. "hest segments you percussed or vibrated
9. "haracteristics of the secretion e0pelled, including color, amount, odor, viscosity, and
the presence of blood.
:. )atients tolerance of the chest physiotherapy
;. Areath sounds before and after treatment
*. "omplications and your interventions
!uscultated rhonchi in 4 upper lobe. )atient placed on right side in trendelenburg
position. "hest physiotherapy and postural drainage performed for /> min, from lower to
middle then upper lobes as ordered. )roductive cough produced large amount yellow
tenacious sputum. )atient tolerated procedure without difficulty, lungs clear to
auscultation.
7echanical ventilation
' or patients receiving mechanical, initially chart(
/. $ate and time the mechanical ventilation began
6. Type of ventilator used and its settings
+. )atients responses to mechanical ventilation, including his vital signs, breathe
sounds, use of accessory muscles, secretions, intake and output, weight, and arterial
o0ygen saturation reading.
' Throughout mechanical ventilation
/. !dCusts made in ventilator settings as a result of !A? levels
6. !dCustments of ventilator components, such as draining condensate into a collection
trap and changing, cleaning or discarding the tubing.
+. Interventions to increase mobility, protect skin integrity, or enhance ventilation% for
e0ample, active or passive range of motion e0ercises, turning or positioning the
patient upright for lung e0pansion.
9. )resence and characteristics of secretions
:. Type and fre&uency of oral care provided
;. !ssessment findings relater to 43", peripheral circulation, urine output, decreased
cardiac output, fluid volume e0cess, or dehydration.
*. )atient and family teaching in preparation for the patients discharge, especially that
associated with ventilator care and settings, artificial airway care communication,
nutrition, and therapeutic e0ercise.
<. Teaching discussions and demonstrations related to signs and symptoms of infection
and e&uipment functioning.
@entilation weans started, placed 9>M T'piece from =(+> am to />(+> am. 3
2 sat.
8emained above =>M during the entire weaning period. 8espiratory assessment
unchanged from flow sheet, patient in no distress at present.
Nasogastric tube insertion and removal
' !fter you insert an N?T, record(
/. Type and size of the N?T
6. $ate, time, insertion route 1left naris, right naris, oral2, and reason for insertion
+. Type and amount of suction
9. !mount, color, consistency and odor of the drainage
:. .ow the patient tolerated the insertion procedure
;. #igns and symptoms of complications such as nausea, vomiting, and abdominal
distension.
*. 7ethod of placement verification.
<. #ubse&uent irrigation procedures and problems occurring afterward.
P/6 fr. N? tube placed in right naris. )lacement verified by L'ray and tube attached to
low intermittent suction, as ordered. $rainage dark brown% heme O. $r. "iruCano notified.
.ypoactive bowel sounds in all four &uadrants. )atient tolerated procedure well.
' !fter the tube was removed(
/. $ate and time of removal
6. .ow the patient tolerated the procedure
+. Dnusual events accompanying tube removal, such as nausea, vomiting, abdominal
distention, and food intolerance
9. Aowel sounds
#eizure management
' If the patient had seizure while hospitalized
/. ,hat type of seizure precaution you took
6. $ate and time the seizure began and its duration
+. )recipitating factors, including aura like sensations reported by the patient.
9. Involuntary behavior occurring before the seizure, such as lip smacking, chewing
movements, or hand and eye movements
:. Incontinence during the seizure
;. )atients vital signs as response to the seizure
*. ,hat medications you gave
<. "omplications resulting from the medications or the seizure and your interventions
=. Kour assessment of the patients post seizure mental status
/>. ,hat and when you reported to the doctor.
!t +(9: pm patient observes with generalizes tonic clonic seizure activity lasting +
minutes. !wake at time of onset and stated. F.ere it comesG patient had urinary
incontinence during seizure, side rail pads in place prior t seizure. )laced on left side,
airway patent. $r. "iruCano notified of seizure. $iazepam /> mg given I@ as irdered.
)atient sleeping as present, vital signs stable.
#uture and staple removal
/. $ate and time the sutures were removed
6. !ppearance of the suture line
+. !ppearance of the wound site, including the presence of purulent drainage
9. If and when you notified the doctor
:. If and when you collected a specimen and sent it to the laboratory for analysis.
Tube feeding
/. )atients tolerance of the procedure and the feeding formula
6. !ssessment of bowel sounds
+. Hind of tube feeding the patient is receiving 1duodenal or CeCenum, continues drip or
bolus2
9. !mount, rate, route and method of feeding 1with continues feeding, document the rate
hourly2
:. Time you replaced the tube and how the patient tolerated the procedure, if applicable
;. Time you flushed the tube and the type and amount of solution used, if applicable
*. !mount of gastric residual, if applicable
<. $escription of the patients gastric function, including prescribed medications or
treatments to relieve constipation or diarrhea
=. Drine and serum glucose, serum electrolyte, and blood urea nitrogen lecels as well as
serum osmolality values
/>. eeding complications, such as hyperglycemia, glycosuria, and diarrhea
//. )atient d family teaching if the patient will continue receiving tube feeding after
discharge
3btaining an arterial blood samples
/. )atients vital signs and temperature
6. !rterial puncture site
+. 8esults of !llens test
9. Indications of circulatory impairment, such as swelling, discoloration, pain,
numbness, or tingling in the bandaged arm or leg, bleeding at the puncture site
:. Time you drew the blood samples
;. .ow long you applied pressure to the site to control bleeding
*. Type and amount of o0ygen therapy that the patient was receiving. 1if applicable2
Need an !A? !nalysisQ Thats another formI
,hen filling out a laboratory re&uest form for !A? analysis, include(
/. )atients current temperature and respiratory rate
6. .is most recent hemoglobin level
+. raction of inspired o0ygen and tidal volume if hes receiving mechanical ventilation
".!8TIN? !##I#T-$ )83"-$D8-
,hen you assist a doctor during a procedure, you have the added responsibilities of
providing patient support and teaching, evaluating the patients response, and carefully
documenting the procedure.
)rocedures may change, but the charting remains the same
8egardless of the procedure, you must always document(
/. $ate, time and name of the procedure
6. $octor who performed it and assistants who may have helped
+. .ow it was performed
9. .ow the patient tolerated it
:. !dverse reactions to the procedure, if any
;. !ny teaching provided to the patient
The section that follows describes documentation for several procedures during
which you may assist the doctor.
Aone marrow aspiration
!fter assisting the doctor with bone marrow aspiration, document(
/. $ate and time of the procedure
6. Name of the doctor performing the procedure
+. .ow the patient responded to the procedure
9. 4ocation and appearance of the aspiration site, including bleeding and drainage
:. )atients vital signs after the procedure
;. Teaching provided to the patient
Aone marrow aspiration e0plained to pt with &uestions answered. 8efer to pt. education
sheet for specific instruction and pt. responses. Aone marrow aspiration on left iliac crest
performed by $r. 8. ,allace at >=9:. No bleeding at site. #pecimens set to lab as
ordered. 7aintaining bed rest. @ital signs stable. )t tolerated procedure well. )t. denies
any discomfort
-#3).!?-!4 TDA- IN#-8TI3N !N$ 8-73@!4
!fter assisting with esophageal tube insertion or removal, document(
/. $ate time that you assisted in the insertion or removal
6. Name of the doctor who performed the procedure
+. Intragastric ballon pressure, amount of air inCected into the gastric balloon port,
amount of fluid used for gastric irrigation, and color, consistency, and amount of
gastric return before and after lavage 1if applicable2
9. Aaseline intraesophageal balloon pressure, which varies with respirations and
esophageal contractions
:. )atients tolerance of the insertion and removal procedures
;. )atients vital signs before, during, and after the procedure.
!t /+(6> #engstaken'blakemore tube placed by $r. T. ,eathers via left naris. :> cc air
inCected into gastric balloon, then :>>cc air inCected into gastric balloon after abdominal
0'ray confirmed placement. Tube secured to football helmet traction. 4arge amount of
bright red blood drainage noted. Tube irrigated with /,<>> ml of iced N## until clear.
-sophageal balloon inflated to +>mm hg and clamped. @ital signs stable. -&ual breath
sounds bilat. )t tolerated procedure well. -motional support given.
!8T-8I!4 4IN- IN#-8TI3N !N$ 8-73@!4
,hen assisting a doctor whos inserting an arterial line, record(
/. $ate and time
6. $octors name
+. Insertion site
9. Type, gauge, and length of the catheter
:. )atients response to the procedure, including circulation to the involved e0tremity.
!t/<(6> 6>g 6 R arterial catheter placed in left radial artery and sutured in place by $r T.
,atson after !llens test transducer leveled and zeroed. 8eadings accurate to cuff
pressures. #ite without redness, swelling or ecclymosis. $ress per protocol. 4ine flusless
easily. !rterial waveform visible on monitor. .and warm and pink with brisk capillary
refill
T.- !8T-8I!4 4IN-# ,38H 7!K A- $3N-, ADT N3T K3D8#J.
!fter removing the arterial line, record(
/. $ate and time
6. $octors name
+. 4ength of the catheter
9. "ondition of the insertion site
:. #pecimens that were obtained from the catheter for culture
;. )atients response to the procedure
*. !mount of time pressure was held at site.
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,hen you help the doctor insert a central venous 1"@2 line, you need to document(
/. time and date of insertion
6. doctors name
+. length and location of the catheter
9. solution infused
:. patients response to the procedure
;. time that 0'rays were done to confirm correct placement, the results, and when you
notified the doctor of them. !lso document if more than one attempt was made to
insert the catheter
!t />+>, procedure e0plained to pt and consent obtained by $r. -. 8afferty. Triple'lumen
catheter placed by $r. -. 8afferty on 6
nd
attempt in left subclavion. "atheter sutured in
place and dressing applied as per protocol. !ll lines flushed with : ml N##. )ortable
chest 0'ray obtained to confirm placement. )t tolerated procedure well. @ital signs stable.
#ee ya "@ line, its time to documentJ.
!fter assisting with removal of a "@ line, record(
/. Time and date of removal
6. Type of dressing applied
+. "ondition of the insertion site
9. "atheter specimens you collected for culture or other analysis.
4D7A!8 )DN"TD8-
$uring a lumbar puncture, observe the patient closely for signs of complications, such as
in 43", dizziness, or changes in vital signs. 8eport these to the doctor immediately and
document them carefully.
!lso document(
/. "olor and clarity of the fluid obtained
6. Number of test tubes sent to the laboratory for analysis
+. .ow the patient tolerated the procedure
9. 3bservations about the patients condition and your interventions, including keeping
him in a supine position for ; to /6 hours, encouraging fluid intake, and assessing for
headache and leaking cerebrospinal fluid around the puncture site.
)!8!"-NT-#I#
,hen caring for a patient during and after paracentesis, document(
/. $ate and time of the procedure
6. )uncture site
+. ,hether the site was sutured
9. !mount, color, viscosity, and odor of the initially aspirated fluid1also, record this in
the intake and output record2.
,ith responsibility comes core charting
If youre responsible for ongoing patient care, document(
/. 8unning record of the patients vital signs
6. re&uency of drainage checks per facility protocol
+. )atients response to the paracentesis
9. "haracteristics of the drainage, including color, amount, odor, and viscosity
:. )atients daily weight and abdominal girth measurements 1taken at about the same
time every day2
;. ,hat fluid specimens were sent to the laboratory for analysis
*. )eritoneal fluid leakage, if any. 1be sure to notify the doctor and chart the time and
date.2
!t /+>>, procedure e0plained to pt and consent obtained by $r. T. ,olf $r. T. ,olf
performed paracentesis in 44N as per protocol. /,<>> ml of straw colored fluid drained
and sent to lab as ordered. #ite sutured with two +'> silk sutures. #terile 9G 0 9G gauze
pad applied. No leakage noted at site. !bdominal girth 9<G preprocedure and 9: S post
procedure. ,eight 6/> lb preprocedure and 6>: lb postprocedure. Aefore the procedure,
pt. stated, Im afraid of this procedure. 8einforced teaching as per teaching flow sheet
and offered support. !fter procedure, pt. stated Fthat wasnt as bad as I thought it would
be.G
T.38!"-NT-#I#
,hen assisting with thoracentesis, you need to document(
/. $ate and time of the procedure
6. Name of the doctor who performed it
+. !mount and characteristics of fluid aspirated
9. )atients response to the procedure
:. If the patient had sudden or unusual pain, faintness, dizziness, or changes in vital
signs and when you reported these problems to the doctor
;. #ymptoms of pneumothora0, hemothora0, subcutaneous emphysema, or infection as
well as when you reported them to the doctor along with your interventions
*. ,hen you sent a fluid specimen to the laboratory for analysis.
!t //>> procedure e0plained to pt and consent obtained by $r. . 7c"all. )t positioned
over secured bedside table. 844 thoracentesis performed by $r. . 7c"all without
incident. #terile 909G gauge dressing applied to site% site without redness, edema, or
drainage. =>>ml straw colored fluid aspirated and specimens sent to lab as ordered. @ital
signs stable. 4ungs clear to auscultation. )atient reports pain at site as / on a > to />
scale.
".!8TIN? 7I#"-44!N-3D# )83"-$D8-#
$ocumentation isnt limited to procedures you perform or help the doctor perform. Koull
also chart in other situations, including the ones described here.
$I!?N3#TI"# T-#T#
Aefore receiving a diagnosis, the patient usually undergoes testing, which can be as
simple as a blood test or as complicated as magnetic resonance imaging. 8ecord in the medical
record all tests and how the patient tolerated them.
".!8T K3D8 I8#T I7)8-##I3N#
#tart your documentation by recording preliminary assessments you made of the patients
condition. or e0ample, chart if shes pregnant or has allergies because these conditions might
affect the way a test is performed or the tests result. If the patients age, illness, or disability
re&uires special preparation for a test, record this information as well.
!lso chart what you taught the patient about the test and follow'up care, the
administration or withholding of drugs and preparations, special diets, food or fluid restrictions,
enemas, and specimen collection.
!t >;>>, 69 hr test for urine protein started. )t instructed on purpose of test and how to
collect urine. $emonstrated correct techni&ue. #ign placed on pts door and in bathroom.
#pecimen container placed on ice in bathroom.
)!IN "3NT834
In your &uest to eliminate or minimize your patients pain, you may use a number of
assessment tools to determine the degree of pain. ,hen you use these tools, always document the
results.
,hen charting pain levels and characteristics, determine whether the pain is internal,
e0ternal, localized, or diffuse and whether it interferes with the patients sleep or other activities
of daily living. $escribe the pain in the chart using the patients own words.
T8!N#4!TIN? A3$K 4!N?D!?-
Ae aware of the patients body language and behaviors associated with pain. $oes he
wince or grimaceQ $oes he move or s&uirm in bedQ ,hat positions seem to relieve or worsen the
painQ ,hat other measures E such as heat, cold, massage, or drugs E relieve or heighten the painQ
!lso, note if the pain appears to worsen or improve when visitors are present. $ocument all of
this information as well as your interventions and how the patient responded.
!t ><>> )t admitted with osteosarcoma and severe lower back pain. )t. rates pain as < on
scale of >'/>. .as been taking ibuprofen <>>mg ;h at home without relief. $r. #. Hobb
notified, 7orphine 6 mg ordered and given I.@. at >=/: vital signs stable. )t states pain
now a 6 on a >'/> scale.
INT!H- !N$ 3DT