1. 4-1 Chapter 4 Nurse Note Documentation Level 1 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

2. 4-2 Chapter 4 Content LO 4.1 Nurse Note Components LO 4.2 Documenting a Nurse Note – Level 1 LO 4.3 Chief Complaints LO 4.4 Vitals (Vital Signs) LO 4.5 Exam (Physical Assessment)

3. 4-3 LO 4.1 NURSE NOTE COMPONENTS

4. 4-4 LO 4.1 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

5. 4-5 LO 4.1 Nurse Note Components SOAPIER S = Subjective O = Objective A = Assessment P = Plan I = Intervention E = Evaluation R = Revision/resolution

6. 4-6 LO 4.2 DOCUMENTING A NURSE NOTE

7. 4-7 LO 4.2 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)

8. 4-8 LO 4.2 Documenting a Nurse Note Documentation methods – Pop-up text – Copy previous notes – Type

9. 4-9 LO 4.3 CHIEF COMPLAINTS

10. 4-10 LO 4.3 Chief Complaints Chief Complaint – Issue that prompted patient to seek care – Subjective – Should be documented in patient’s words as quote

11. 4-11 LO 4.4 VITALS (VITAL SIGNS)

12. 4-12 LO 4.4 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

13. 4-13 LO 4.4 Vitals (Vital Signs) Vitals – Objective measurements – May add three additional measurements such as: Pulse oximeter Pain scale Height of fundus in pregnant women

14. 4-14 LO 4.4 Vitals (Vital Signs) Vitals graphs – Blood pressure – Height – Weight – BMI Includes children’s growth charts

15. 4-15 LO 4.5 EXAM (PHYSICAL ASSESSMENT)

16. 4-16 LO 4.5 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 and Lock – Upon completion of documentation in Nurse Note