Nursing Documentation

Nursing Documentation

Objectives

• List the purpose of documenting patient care

• List types of patient care records and forms used by US Navy

• List the components and guidelines for writing SOAP notes and Nursing Notes

• List types of patient care information to be documented

Purposes for documentation of Patient care

• To provide a written account of Pt’s condition, treatments, progress, and response to care.

• Legal Record.

• Continuity of pt care

 

Types of Patient Care Records

• Outpatient Record

• Inpatient Record

• Dental Record

 

Patient Documentation Forms

• Chronological Record of Medical Care (SF 600)

• Nursing Notes (SF 510)

• Report of Medical History (DD Form 2807)

• Report of Medical Examination (DD Form 2808)

 

Chronological Record of Medical Care

• Also known as SF 600

• Entries include the following:

  • Identification Data
  • Date/Time
  • Treating Organization/Facility
  • Initial entry of care
  • Discharge instructions and f/u instructions

Chronological Record of Medical Care

 

Proper documentation using the SF 600

• SF 600’s are written using the SOAP note format.

• All initial entries must contain:

  • Chief complaint/hx of complaint
  • Physical exam and clinical finding
  • Analysis of clinical findings
  • Tx accomplished/follow-up care, and medication.
  • Each entry must be SIGNED!
  • Remember if it is not signed, it didn’t happen!!!

Proper documentation using the SF 600

 

What is a SOAP note?

• A SOAP note consists of a Subjective, Objective, Assessment, and Plan data.

• Subjective

– What the pt is telling you

– “use quotation marks when needed”

– Avoid personal judgments

• Objective

– The data you obtain from vital signs, physical exams, previous lab, and x-ray findings

• Assessment

– What your diagnosis will be using the information gathered from the subjective and objective

• Plan

– What your actions are going to be to help resolve medical condition.

– This can include medications (with instructions), labs, x-rays, pt education, f/u, consultations, ect.

SOAP note

 

Proper documentation of a nursing note.

• Also referred to as an SF 510.

• Used for inpatient care

• Components of SF 510:

– Date of entry

– Time of entry

– Observations

– Patient identification

Proper documentation of a nursing note.

 

How to document using SF 510 format

• Written /filed in chronological order

• Format directed by local policy

Each note signed by the person who wrote the note!!!

• Must use black ink

• Be brief

DO NOT SKIP LINES!!!

• Use standard abbreviations

– If you do not know the correct abbreviation do not make up your own, just spell it out.

– Please be familiar with the command’s standard abbreviation list. Some abbreviations are no longer used.

• If you make an error draw a single line through it and label “error” above with your initials, then continue note with correct info.

document using SF 510 format

• Late nursing note;

– Write “late entry” in AM/PM column followed by time and date of entry.

• A nursing note may be more than 1 page or less than 1 page.

• If your nursing note is less than 1 page, draw a line through empty spaces and label with “no further entries”

 

Nursing note entries also include:

• Mental status

– Orientation

– Observed mood/behavior

– Expressed concerns

• Physical assessment

– Abnormal VS (must be written in red ink and circled)

– Sensory/perceptual

– Neurological

– Skin

– Respiratory

– Gastrointestinal

– Genitourinary

– Musculoskeletal

– Reports of discomfort

• Nursing care, tx’s, and procedures

Nursing notes

Medications that require a Nursing Note

• One –time drug orders

• STAT Orders

• Pre-op medication/sedatives

• PRN Medications

 

More Nursing Note information that needs documentation

• Visits made by pertinent people or other hospital staff

• Patient’s response to meds

• Patient’s tolerance of procedures or tx’s

• Document name, rank of physician or nurse notified about abnormality or change in patient’s condition.

– This includes VS, physical /mental changes.

– This also includes positive changes.

• Safety measures

• Patient transportation

• All entries must be signed by person writing note(s).

• Remember if it isn’t documented or signed it didn’t happen, and that could spell DISASTER!!!!

 

Report of Medical History DD Form 2807

This form has replaced the SF 93

Report of Medical Examination DD Form 2808

This form has replaced the SF 88

These forms are used to document Physicals for enlistments, inductions, appt. for retentions, and medical boards

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