Essential Nursing Notes Guide
Translated by
ScribdTranslationsEssential Nursing Notes Guide
Translated by
ScribdTranslationsNursing Notes
Foundation
The nursing note is the result of the needs
manifested by the same staff, in the existential area,
administrative and teaching, aims to integrate into
a single document with the largest amount of patient data
to carry out a complete assessment and in this way
establish therapeutic measures and specific care
for the same in a timely and effective manner; on the other hand
It also allows to reduce the time that the nurse
dedicated to administrative activities and this time it
dedicated to direct attention and comprehensive care of the patient
in the physical-emotional, social, and spiritual areas and not only to
the 'disease'.
Nursing Notes: It is a document in the
which is recorded objectively, clearly,
concrete, understandable and systematic of the
findings, activities, observations
decisions and care provided to the person,
family or community, immediately
after its completion.
•
The nursing notes must be adjusted to the
ethical principles of truth, privacy,
respect for the patient and must take into account
all the legal implications that this requires
document.
The medical history shows elements that characterize it,
which will be analyzed below:
•
1. It is a private document. A document is understood to be any object.
mueble que incorpore un escrito o unos datos que para estos efectos
it can be signed and has evidentiary value.
The private character refers to the fact that the document does not require
legal formalities other than the author's signature are not granted
neither by a public official in the exercise of their functions, nor by a notary.
2. It is mandatory. This means that all those professionals,
technicians and assistants who are linked by their profession or trade
with the specific clinical case, they must record their observations,
concepts, decisions, and results of the health actions developed.
The medical record is subject to professional secrecy.
well, it is the duty of all professionals that
intervene in the clinical case keep a reserve of it
that has been seen, heard, and understood by reason of the
professional practice.
4. The medical history belongs to the patient and only
it may be known to third parties, with prior authorization
of the patient, the family or their legal representative in the
cases provided for by law.
Nursing notes contain the same elements as the History
Clinic and it must be filled out considering the following
conditions:
Adopt the formats and means of recording that meet the needs of
information that should be kept regarding nursing care that is
they provide care subjects according to the levels of complexity without detriment to the
compliance with regulations, institutional guidelines, or authorities
competent
Make the records immediately after providing the care,
clearly identifying the activity or procedure.
Describe clearly, legibly, without crosses out, corrections, without using acronyms and
without leaving blank spaces.
Each annotation must include the date and time it is made along with the name.
complete and signature of the author thereof.
Objectively describe the behavior and reactions of the care recipient.
When registering, avoid characterizing the behaviors of the person under care
with ungrateful or disrespectful adjectives such as stubborn, repugnant,
offensive, unpleasant, rude.
Properly correct the incorrect notes by drawing a line over them.
the annotation and writing next to it "incorrect annotation" or "no
"valid" and then sign below.
The blotches can be interpreted as falsification of records and
they can be classified as a test of conscious negligence from
the legal point of view.
In case of attending, in case of emergency, a verbal medical prescription.
A detailed transcription of it must be made immediately.
specifying: the date, time, and name of the doctor, means of
communication and the prescription. Do not forget to have it registered by the doctor.
Nursing notes must be truthful, protect the reserve
from the medical history, the privacy and intimacy of the patient.
Nursing notes must promote the
unity and interdisciplinary work,
respectful, with a view to ensuring the quality of
nursing care that is provided to
subject of care.
RESPONSIBILITY OF NURSING NOTES
•
Nursing notes presume the veracity of the data and as it has already been
said, from the legal dimension, just like the medical record is a
document with outstanding evidentiary capacity, subject to analysis and
investigation within the processes of professional responsibility, is
it is advisable for nurses to not only fill out the notes of
nursing of those patients who are considered critical but also those
other nursing records such as the fluid intake and output chart
medications, vital signs, etc., taking into account the act of
nursing care, since the written record of the act of care does not
it only reflects the professional exercise but is the proof of the
human, ethical, technical, and scientific guidelines developed.
Let us remember that the act of care that is not recorded means that it is not
carried out in legal terms.
It is important to keep in mind that the great
most of the time the mistakes in the exercise
professional are of the "guilty" modality, that is
for the violation of the objective duty of care that
the nurse should have predicted for being
foreseeable or having foreseen, trusted in
to be able to avoid it, which is different from the modality of
the behavior of the two mentioned types
previously, which is "dolus" (intention).
Every sheet or hospital bed sheet must have a
header that is the name of the patient their number of
clinical history that is the number that the institution assigns to it
assigns the date of their entry to the medical center at the time of admission
day to make the note the time at which it is made or was made
a procedure that, no matter how minimal, must be present
registered and above all, a brain register must be made
flow of the patient's condition being treated,
highlight your priorities such as state of awareness,
skin condition, oral fluid infusion and
intravenously either through a peripheral vein or through a central catheter
or some other type of route such as epidural, subcutaneous, etc;
observation of surgical wounds, insertion sites
like tubes, drains, probes, etc.
a) Narrative notes.
The narrative documentation is the method
traditional record keeping of care
nursing, is the most known for the
nurses, it is simply about training a
format similar to a story, for documentation
the specific information about patient care
what happens the turn. In it is recorded: status of
patient, interventions, treatment and the
patient responses to treatment.
Advantages:
•
Easy access to the location of the forms and
the subsequent documentation of each discipline.
As the oldest method of creation of
graphs, is the one that is most familiar to the
nurse.
It does not require the organization of the notations of the
organizations of the subject but this
organized over time.
Disadvantages:
•
The fragmentation of the documentation of the
patient care according to who the provider is
the same.
The scattered documentation of teaching, when
is performed by various disciplines, such as nursing,
nutrition and others.
The narrative notes are not organized by themes.
making it difficult to recover data about a
determined problem.
Trends in very long graphics, which often
they duplicate the information provided in the course sheets
clinical.
b) Problem-oriented annotations (SOAPIE).
It is the documentation-oriented system for
problem parallel to the nursing process
includes data collection, identification
of patient responses, the development of the plan
of care and the evaluation of achievement of
the objectives. In this system, the information is
focused on the patient's problems, and this
integrated and registered by all disciplines,
using a constant format.
The acronym SOAPIE corresponds to the following
contents:
•S: Subjective Data. Includes feelings,
patient symptoms and concerns should be documented
the words of the patient or a summary of the
conversation.
O: Objective data: It consists of the findings obtained
during the assessment; they are discovered by the sense of the
sight, hearing, touch, and smell or by instruments such as the
thermometer, sphygmomanometer, auxiliary exams, etc.
A: Interpretations and analysis of the data: It may be
real or potential and it always goes with 'related to' for
determine the determining or conditional factors
and the NANDA diagnostic code.
•P: care plan: the objective is recorded
planning, understand what the illness plans
to do.
I: intervention or execution. It refers to executing the
plan designed with the purpose of resolving the
identified problems.
E: Evaluation of the expected results: it is evaluated the
effectiveness of the intervention carried out; recorded in
present. It concludes with the school seal and stamp of
the nurse who attended to the patient.
SOAPIER Example
I’m very hot, uncover me a little and wet my head.
• Temperature 38.5ºC, sweating, redness.
A: Hyperthermia related to infectious process.
P: lower body temperature.
I: Hourly temperature control, application of physical means,
administration of prescribed antipyretics and increased fluids
orally. Then Dr. Pérez was informed.
The patient continues with treatment.
The observed response in the patient is a decrease in temperature.
37.2 ºC.
•
SIGNATURE AND SEAL
ZIP Code.
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c) Focus annotations:
It is a method of organizing information.
second notes from the nurse and they are
structured into three categories:
•
D: Subjective and objective data.
A: action is the nursing intervention that
has executed.
R: response, it is the reevaluation of the effectiveness of
the interventions.
•
The Data Category
The data category is like the assessment phase.
of the nursing process. It is in this category
that you would be writing your assessment
cues like: vital signs, behaviors, and other
observations noticed from the patient. Both
subjective and objective data are recorded in
the data category.
The Action Category
The action category reflects the planning and
implementation phase of the nursing process
and includes immediate and future nursing
actions. It may also include any changes to the
plan of care.
The Response Category
The response category reflects the evaluation
phase of the nursing process and describes
the client’s response to any nursing and
medical care.
Focus Charting Samples
Date/Time Pain
The focus of this problem is pain. Notice the way the D, A, R were written.
5/20/2010 8:00 PM Pain D:>Reports of sharp pain on
m the abdominal incision area
with a pain scale of 8 out of
10>Facial grimacing>Guarding
behavior>Restless and irritable
A:
Administered Celecoxib
200mg IV
Encouraged deep breathing
exercises and relaxation
techniques
Kept patient comfortable and
safe
Hyperthermia
5/20/20108:00pm Hyperthermia
Temperature of 38.9OC via
axilla>Skin is flushed and warm to
Tepid Sponge Bath (TSB)
done
7:30pm>Administered 250mg IV
Paracetamol as per doctor's order
Encouraged adequate oral fluid
intake
Encouraged adequate rest
R:
10:00pm>Temperature decreased
from 38.9 to 37.1OC