Chapter 4 - Nurse note documentation, level 1. After completing Chapter 4, the students will be able to: Describe the components of a nurse note, carry out documentation of a nurse note, use chief complaints, carry out documentation of vitals (vital signs), carry out documentation of an exam (assessment). | Chapter 4 Nurse Note Documentation Level 1 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 4 Content LO Nurse Note Components LO Documenting a Nurse Note – Level 1 LO Chief Complaints LO Vitals (Vital Signs) LO Exam (Physical Assessment) LO NURSE NOTE COMPONENTS LO 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 LO Nurse Note Components SOAPIER S = Subjective O = Objective A = Assessment P = Plan I = Intervention E = Evaluation R = Revision/resolution LO DOCUMENTING A NURSE NOTE LO 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) | Chapter 4 Nurse Note Documentation Level 1 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 4 Content LO Nurse Note Components LO Documenting a Nurse Note – Level 1 LO Chief Complaints LO Vitals (Vital Signs) LO Exam (Physical Assessment) LO NURSE NOTE COMPONENTS LO 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 LO Nurse Note Components SOAPIER S = Subjective O = Objective A = Assessment P = Plan I = Intervention E = Evaluation R = Revision/resolution LO DOCUMENTING A NURSE NOTE LO 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) LO Documenting a Nurse Note Documentation methods Pop-up text Copy previous notes Type LO CHIEF COMPLAINTS LO Chief Complaints Chief Complaint Issue that prompted patient to seek care Subjective Should be documented in patient’s words as quote LO VITALS (VITAL SIGNS) LO 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 LO Vitals (Vital Signs) Vitals Objective measurements May add three additional measurements such as: Pulse oximeter Pain scale Height of fundus in pregnant women LO Vitals (Vital Signs) Vitals graphs Blood pressure Height Weight BMI Includes children’s growth charts LO EXAM (PHYSICAL ASSESSMENT) LO 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 .
