Documentation Part 1 foundations with abbreviations

BID

twice a day

TID

three times a day

QID

• Four times a day

PRN:

• As needed

ac:

before meal

pc:

after meals

PO:

• By mouth

NPO:

nothing by mouth

RUE

Right Upper Extremity

RLE

Right lower extremity

LUE:

• Left Upper Extremity 

LLE:

• lower left extremity

• RUQ:

• Right Upper Quadrant 
  

RLQ:

• Right Lower Quadrant Left Upper Quadrant 

• LUQ:

• Left Upper Quadrant 

• LLQ:

Left Lower Quadrant

CL:

• Clear Liquid diet

FL:

• Full Liquid diet

NAS:

• No Added Salt

ADA:

american Diabetes Association

TF:

• Tube Feeding (enteral feeding)

PPN:

• Peripheral Parenteral Nutrition

TPN:

• Total Parenteral Nutrition

I & O:

• Intake & Output

BRP

• Bathroom Privileges

BSC:

• Bedside Commode

HOB:

• Head of Bed

Ad Lib

• At Liberty (as desired)

BR:

Bedrest

OOB:

• Out of Bed

ROM:

• Range of Motion

SCDs:

• Sequential Compression Devices

TCDB:

Turn, Cough, Deep Breathe

IS:

• Incentive Spirometer

GENERAL GUIDELINES:

Document FACTS ONLY;

• use quotes when possible, but be sure they are accurate

GENERAL GUIDELINES:

Be concise & specific

“avoid generalizations, such as “patient doing well.” Don’t use labels, such as noncompliant, combative, disruptive, or difficult, to describe patients. Instead, concisely note the behavior — “patient refused IM injection” or “patient rates his pain at 6 on a scale of 1 to10.”

• Do not include any unnecessary information

general guidlines document plans?

• DO NOT DOCUMENT PLANS 

  • i.e. Will return to assess pt. in 30” or will notify MD…instead document MD notified along with any orders received after the call is completed

what do i check?

• check your spelling…this is the pt.’s permanent record

• All entries must be

• dated, timed & include your signature

  • First initial, Last name, credentials Ex) A. Jackson SN, CUI

NOTE: The signature must reflect your legal name (the name on your badge and license)                                                                       

Ex) If your name is Albert but you prefer to be called Jack you MUST Sign A. Jackson SN CUI NOT J.  Jackson SN CU

PAPER DOCUMENTATION

• Generally Black or Blue ink only (check organization Policy & Procedure)

• Legible

• Cross out errors with a single line and write error followed by your name

  • Lung sounds diminished in left (cross out)right base posteriorly.

• Do not skip lines

• COMPUTERIZED DOCUMENTATION

• You can change the time stamp, but there is always an underlying mark to indicate when the note was written.

• It is important to try to document as close to the time of the event as possible

Scenario

• Your patient is complaining of a headache and there is no pain medication ordered

  • Assessment

    • P – palliative or proactive factors                                                                      (what makes it better/worse)

    • Q – quality (how would you describe it)

    • R – Region/Radiation (show me where it hurts)

    • S – Severity (0-10 scale)

    • T – Timing (constant, intermittent)

    • GET A SET OF VITAL SIGNS (VS)

What do you do now???

• need to call MD

  • Oh No….What else do you need to have available

    • Access to patient chart

    • Know Labs, medications, ALLERGIES

• How do I Organize the Information

• iSBAR

  • I: Hi Dr. Jones this is ______ calling from Concordia Hospital about your patient Ms. Smith in room 101

  • S: Ms. Smith is experiencing a right sided headache 7/10 that she describes as “constant & throbbing”. 

  • B: She has no allergies and states that she often experiences headaches

  • A: Her VS are stable but her BP is now slightly elevated at 145/85. The HA began about 30 minutes ago and she has had no relief from non-pharmacological interventions.

  • R: Ms. Smith states that two extra strength Tylenol usually “do the trick”. May I have an order for this? Would you like to order additional pain medication in case this is not effective or wait until you see her this afternoon?

telephone Order…Don’t Panic!

• What do I need to do???

  • READ BACK!!!

    • Make sure you have all the information (dosage, frequency, spelling of MD name…)

  • Transcribe the order

    •  date/time

    • Exact order

    • TORB MD Name/ Your name and credentials

PATIENT FOCUSED…NOT NURSE FOCUSED

• Describe what happened to the patient (patient focused)

  • Abdominal wound packed using sterile technique

  • 16F Foley catheter inserted w/ sterile technique

  • Patient educated re: need to use call light 

• instead of describing what nurse did (nurse focused)

  • Packed abdominal wound using sterile technique 

  • Used sterile technique to insert 16F Foley catheter 

  • Educated patient re: need to use call light