The Nurse/Midwife's Handbook - A Dictionary

Writing Patient Notes

Nursing Admission Notes

8S Nsg: Pt. QADDS=?, GCS=?. Admitted from ___/for ____. Bloods taken, ___. Nil skin integrity concerns on admission, mobility ___, diet___, admission paperwork completed ___. Wound observations:___ . Abdo soft & slightly tender due to ___. Dx dry & Intact. IDC, PICC, PIVC, ___ insitu. B/vac x2 on suction, ___ etc. Plan. Designation, Name, Signature ————

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Nursing Discharge Summary

Admitted to ward for pre operative cares and prepared for theatre. Patient attended theatre and returned to ward for postoperative observation and monitoring.
IV cannula
IV therapy
L) hand dressed with Mepitel, white gauze clean dry and intact.
Neurovascular observations maintained.
Post operative milestones met.
Tolerating normal diet and thin fluids.
Nil pain or nausea.
IVC removed.
Script provided for antibiotics.

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Patient admitted on the DD/MM/YYYY for preoperative cares and prepares for theatre.
Patient attended theatre and returned to ward for postoperative observation and monitoring on the DD/MM/YYYY @ approx 1000 hours.
IV cannula & IV therapy insitu on return to ward.
TEDs and SCUDs insitu on return to ward.
1 bellovac drain on suction.
4x keyhole sites dressed and 1x dressing to neck, all dry and intact.
On the DD/MM/YYYY, patient cleared for discharge post review by doctor. Patient meeting all postoperative milestones.
In preparation for discharge, IVC and bellovac removed. All dressings changed, and are dry and intact.
At time of discharge, patient independent tolerating normal diet and thin fluids, passing urine.
Nil pain or nausea.
Patient discharged on the DD/MM/YYYY.

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Nursing Discharge Summary Notes
(We do not diagnose as nurses)

Patient notes in progress notes.

Eg. 1:
Patient QADDS stable = 0. Meds as charted. Scant PV loss. TOV x2 passed. IVC removed. Discharge summary & education given, incl. d/c meds. Nil c/o pain or nausea. Education given to pt to return to MEC if they have difficulty urinating, excessive pain, or large PV loss. Pt. is eager to leave and mother is aware of post op cares required. Nil other complaints ATOR. Discharged as per MD orders.

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Patient Progress Notes

In progress notes, ensure you cover the following:

Cognition
☞ Pt. GCS=? (or patient alert & orientated/orientated to person and acknowledges they are in hospital, but unsure of which hospital, and unable to state the month or year, or, pt. alert, known confusion throughout day, easily redirected.

QADDS
☞ QADDS= ?, and state variations to normal and interventions taken, as well as how they were received. eg., BP 109/69, pt. given jug of water and encouraged to drink fluids, Hypotension resolved at 1200, QADDS=0

Medications
☞ Meds administered as charted,
☞ Any withheld medications WH due to ____eg. movicol WH due to ongoing loose stool.
☞ Any refused meds by pt.

Wounds
☞ Existing wounds, are they dry and intact? How many, what are they, etc.

Drains & Catheters
☞ IDCs, bellovacs, penrose drains, etc. Are they patent, dressings, etc.

IVC/PICC/PORT/CVAD
☞ eg. IVC in R) CF, patent and flushing, dx dry and intact with nil signs of phlebitis.

NGTs
☞ Eg. NGT insitu, line at nose, not moving/dislodging, measuring 55cm at nose, 4/24 aspirates attended to, 20ml total.

Diet
☞ Fasting, tolerating diet and fluids?, diet changes, vomiting, nausea, NBM, etc.

Bowels/Continence
☞ eg., PUIT, BOx2, large type 2, fluids and pear juice encouraged.

Mobility
☞ eg., Mobile and independent with ADLs, seen to be walking around ward frequently
☞ PT. RIB most of shift
☞ mobilising independently to bathroom
☞ Pt. Ax1 with 4ww, consent obtained
☞ or. RIB, bed sponge attended, consent obtained.

Skin Integrity
☞ Skin intact
Stage 1 pressure injury found on pt.'s scrotum, incident report completed, referred to wound care nurse, air mattress ordered, foam dressing applies, 2 hrly PAC attended.

Discharge
☞ Pt. reviewed by dr

Any other concerns to be added

Examples

Nsg 10S: Pt. QADDS = 0, GCS15. PRN pain relief given as charted, stoma pink, warm & active, semi-formed stools. Family visited. Independent with mobility & cares. No c/o nausea this shift, pt. RIB. Nil other concerns ATOR. Designation, Name, Signature ————

Nsg 4A: Pt. QADDS = 1 BP 98 systolic, team leader aware, continuing to monitor. Meds and obs as charted. Continuing QID BSLs + 0200. Neuro obs taken, GCS=15. Moderate c/o pain, analgesia given as charted. L) PIVC insitu. 2x lap sites & 2x bellovacs on suction in situ, dxs d&I. Pt. c/o feeling dehydrated, fluids running as charted. FF diet, RIB. Nil other complaints ATOR. ——— Designation, Name, Signature ————

Nursing 5A: pt. Alert and orientated. QADDS=0. BO, IDC remains insitu draining well, 1200mls clear urine emptied. No c/o pain or nausea, tolerating normal diet and thin fluids. Medications given as charted. Mobilising independently and independent with all personal cares. Nil skin integrity concerns. Pt. RIB comfortably, nil other concerns ATOR. ——— Designation, Name, Signature ————

Nursing 7C: Pt. GCS= 15, QADDS=2 due to SpO2 and 3L O2 via NP. Pt. Incontinent of urine+++, incontinence pad insitu. No C/O pain or nausea this p.m., tolerating normal diet and thin fluids food chart maintained. Medications given as charted L) PIVC insitu, Neil, new skin, integrity, concerns, PAC attended to. Aircell mattress and mepilex heels insitu, PAC chart attended to. All cares as per careplan. Patient continuing with unproductive cough. No other concerns & RIB ATOR. ——— Designation, Name, Signature ————

Nursing 9C: Pt. arrived to ward @ 1405, provided with personal belongings, all baseline and admission documentation completed. QADDS stable, a febrile, Orientated to room & tv system, provided with nurse call bell. White on grey coating with scant streaks of fresh blood to bilateral tonsil beds, nil airway concerns. Nil c/o nausea, moderate pain predominantly when swallowing, analgesia administered with moderate affect. Tolerated small amounts of softer full diet for dinner and thin fluids. Mobilising independently to bathroom, TOV complete, PIVC insitu, dx dry & intact, nil signs phlebitis, nil skin integrity concerns, pt. currently RIB, settled, for nurse-led d/c tomorrow. No other concerns & RIB ATOR. ——— Designation, Name, Signature ————

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