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Nursing Report Writing

Agnes Said:

What is the best report sheet for acute care Nursing Assistants?

We Answered:

Nursing assistant assignment sheet- that I have used for 40 years in both hospitals and nursing homes
pt. name
room and bed #
primary language spoken
needed for dentures glasses or hearing aids
any fluid restrictions
specific assistance in adl's- dressing-feeding-bathing- toiletting etc.
siderails in bed Y-1or2 --N
continent or incontinent- diaper needed?
foley - foley care
# of staff need for transfer- or assistive devices need for transfer
any assistive devices used in wheel chair or ambulating or if patient needs assistance to ambulate or to propel wheel chair
any splints braces or prosthesis
Ted stockings or ace bandages application when oob
if patient is on falls precautions
if patient has any skin breakdown or redness due to immobility
need for positioning devices in wheel chair or bed
head of bed to be elevated at__ degrees when in bed
if on isolation which type
if pt. is prone to choking on foods or liquids
presence of any wounds-sutures-drains or dressings and care of same
if present any redness drainage or odor present and color of drainage
pt. resistive or combative with care Y or N
if pt. can verbalize needs

info on any active or passive R.O.M. with number of times a day and # of repetitions ( include site i.e. uext-lext or all ext.)
if pt. goes to P.T.or O.T. what time they are scheduled for
# of times B/P, T.P.R. per shift and if any site is restricted for B/P (as in a shunt site)
I&O as ordered
turning and positioning schedule
and anything else that is specific or unique to the care of that pt.
it can be a standard form with general information either checked off or written in
with room on back for anything else either you or they need to write in

Clifford Said:

When writing progress notes or a nursing report, what should you NOT do?

We Answered:

Don't obscure any of the entries. Don't change old notes. If today's report seems inconsistent with past reports, you could make note of the inconsistencies, but don't revise the past to make it agree with what you now are reporting. e.g. It would be OK to say "Though visible facial scarring was noted on August 3, the skin now looks to have healed without scars". Of course, if you are going to contradict past notes like that, you should be darn sure you are saying true things on the correct chart for the correct patient.

If you make an error as you write in notes, line through the error and initial it, but don't obscure the erroneous entry (e.g. don't white it out, don't erase it).

Jean Said:

report on the nursing field?

We Answered:

Here's a few:

**Too heavy patient loads.
**Mandatory OT.
**Management's unspoken pressure to bend the rules (& risk personal liability).
**The large abuse of the H1B visa system to import inferior "RNs" from third world countries. ((Done to hold wages down.)) Not all obviously, but you'd probably be quite shocked.
**Enough ideas yet???

Zachary Said:

Nursing report sheet?

We Answered:

Make you own on the computer-then you can tailor it to what things you need to know and have available, not the RN. Then either print out a bunch or xerox them. If you have no computer skills, make a long-hand sketch of what you need and ask someone to do it for you.

Vivian Said:

What contributions does nursing make to the community's health?

We Answered:

They save lives, prevent complications, prevent suffering, and save money.

Gordon Said:

When writing a nursing diagnosis for deficient knowledge, do you use an AEB statement?

We Answered:

Yes...... It most be in PES format. for ex. "Deficient Knowledge ( insulin injections) r/t lack of prior experience, AEB anxiety and asking a lot of questions........"

Francisco Said:

what information/details to include on a nursing report?

We Answered:

you write the problem then your assessment and the your recomendation.

hope that helps

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