Ad
related to: sample nursing assessment notes examples for studentssimplenursing.com has been visited by 10K+ users in the past month
Search results
Results from the WOW.Com Content Network
For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign". The use of medical equipment is routinely employed to conduct a nursing assessment.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses .
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
Substance abuse: note any alcohol, tobacco, and illicit drug use, include type, amount, and duration, as well as any past treatment or drug rehabilitation. Diet: ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment. Medically, however, this is ...
SOCRATES [1] [2]; Letter Aspect Example Questions S Site Where is the pain? Or the maximal site of the pain. O Onset When did the pain start, and was it sudden or gradual?
Ad
related to: sample nursing assessment notes examples for studentssimplenursing.com has been visited by 10K+ users in the past month