Nursing Documentation for Challenging Patient Conditions
Documenting challenging patient conditions is a tiresome task for nurses. This article explains some such conditions and nurses can document each condition.
Nursing documentation is vital to provide safe, ethical and effective care to the patients. The documentation should reflect relevant observations and be completed in a clear, timely, comprehensive, legible, chronological and accurate manner. Inaccurate or incomplete documentation results in fragmented care, repeated tasks, delayed or missed therapies. However, certain patient conditions are as challenging for nurses to document as they are to provide care for. We will see some major challenging patient conditions and tips for effective nursing documentation. The importance of electronic health records (EHRs) and nursing transcription will be discussed later.
Anaphylaxis Anaphylaxis is a severe reaction to an allergen after re-exposure to the substance. It is a lethal response that requires immediate or emergency intervention. If anaphylaxis occurs, nurses should document the following: Date and time at which the anaphylactic reaction began Events leading up to the anaphylactic response Signs and symptoms of patients such as itching, palpitations, chest tightness, agitation, anxiety, flushing, light headedness, throat tightness or swelling, throbbing in the ears, or abdominal cramping Assessment findings such as skin rash, wheezing, unresponsiveness, wheals or welts, arrhythmias, decreased LOC, decreased pressure, angioedema, weak or rapid pulse, and diaphoresis Name of the practitioner notified and the time of notification Emergency treatments and supportive care provided Response of the patient
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You should follow the guidelines given below. When the allergen is identified, document that allergen on the medical record, MAR (Medication Administration Record), nursing care plan, patient identification bracelet, practitioner’s orders and dietary and pharmacy profiles Document appropriate departments and individuals (such as pharmacy, risk management, dietary and the nursing coordinator) were verified Fill out incident report as per facility policy, if necessary
Arrhythmias Arrhythmias are the problems that occur when abnormal electrical conduction or automaticity causes changes in heart rate or rhythm, or both. The severity of arrhythmias varies from mild, asymptomatic disturbances that require no treatment to catastrophic ventricular fibrillation which requires immediate resuscitation. During an arrhythmia, you should document the following: Date and time of the arrhythmia Events that occurred prior to and at the time of the arrhythmia The symptoms of patients and the findings from cardiovascular assessment such as shortness of breath, pallor, cold and clammy skin, palpitations, dizziness, weakness, chest pain, syncope and decreased urine output Patient’s vital signs and heart rhythm (you should place a rhythm strip in the chart if the patient is on a cardiac monitor) Name of the practitioner notified and the time of notification www.medicaltranscriptionservicecompany.com
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Results of a 12-lead ECG ordered Details of your interventions and the patient’s response Emotional support and patient teaching given
Brain Death In 1981, a working definition for brain death was derived by the American Medical Association, the American Bar Association and the President’s commission for the Study of Ethical Problems in Medicine and Behavioral Research. The Uniform Determination of Death Act (UDODA) developed afterwards defined the brain death as the cessation of all measurable functions or activity in every area of the brain, including the brain stem. This definition does not include comatose patients as well as those in a persistent vegetative state. You should be aware of your state’s law regarding the definition of death. The exact criteria for determining brain death may also vary according to the facility. You should include the following into the documentation for a patient undergoing testing for brain death. Date and time of each test Name of the test Name of the person who performs the test and their required documentation Response of the patient to the test, if any Actions taken in response to the patient, course of action when patient had gone into ventricular fibrillation Time and names of people notified of the results Support provided to the family members if they are present
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EHR Transcription and its Significance Unlike written documentation, the electronic health record (EHRs) streamlines the documentation process with templates, predetermined fields and easy accessibility. Nurses can enter the necessary details into relevant fields and access them quickly through an electronic interface. This will help nurses to expedite their documentation during challenging conditions and provide immediate
treatment.
Still,
the
accuracy
and
completeness
of
the
documentation could be marred with copy paste errors (errors that occur inadvertently due to copying and pasting data from previous records frequently) and limited narrative description with templates. Harnessing the utilities of EHRs and medical transcription is thus very important in which the recordings are transcribed by skilled transcriptionists, the transcribed data is subjected to quality checking with proofreaders and editors and then populated into appropriate fields within the EHR. In this way, you can complete your documentation efficiently with improved accuracy.
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