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Methods of Documentation – Examples

Examples of four methods of documentation are included in this section. In each of the examples, the following is printed at the end “Nurse’s signature, designation”, but ensure that you sign your name and insert your specific designation.

 

Narrative method of documentation – Loss of consciousness

Case summary:  A 47-year-old client, identifies as transfemale with pronoun they/their, came into the emergency department after losing consciousness from being struck in the head from a boating accident. According to the client’s partner, the client regained consciousness within one minute.

Date (yyyy/mm/dd)

Time

Discipline

Notes 

2020/10/14

1330

nursing

Client stated it was their first sailing lesson and they were “hit square in the forehead with the mast and I was out.” The client was unconscious for less than one minute according to their partner who was in the boat. After the accident, they immediately sailed back and came to the ER. Client states “I have a headache.” Rates pain 3/10. No dizziness, nausea or vomiting. Vital signs are stable. Client is alert and orientated to person, place, time and self. No difficulty speaking, understanding or answering assessment questions. No weakness or incoordination. Gait is coordinated. Firm hand grasp bilaterally. No history of falls. Pupils are round, equal in size at 3mm, and reactive to light bilaterally. No change in vision. Glasgow coma score 15. The centre of client’s forehead has a red swollen lump approximately 4cm in diameter. Discussed concussion protocols and critical finding signs and symptoms that need immediate medical attention. Encouraged to limit physical and cognitive activities that provoke symptoms and to not engage in physical activities that are higher risk of another concussion while still having symptoms. Client and partner verbalized understanding of critical finding signs and symptoms and to seek care if symptoms get worse or additional symptoms appear. Client will follow up with primary care provider within 24 hours to discuss a gradual return to physical activity plan. Nurse’s signature, designation ———————

 

DAR – Stress

Case summary: A 17-year-old client, identifies as male with pronouns he/his, came into the clinic following a high school counsellor’s suggestion after sharing feeling worried about going to university.

Date (yyyy/mm/dd)

Time

Discipline

Notes 

2020/10/19

1645

nursing

D: Client stated, “I’m feeling really worried about starting university on my own.” Client asked questions about how to control restless mind and how to manage his stress. Vital signs stable. Client restless, fidgeting legs during interview, and chewing on fingernails. A: Discussed client’s fears about transitioning to university. Collaborated with client in identifying stress management techniques client can do prior to going into university including developing a peer support network, positive self talk, and walking daily. Discussed how to access potential resources at university site including learning supports and mental health supports. Follow up appointment booked for three weeks. R: Client acknowledged resources provided and stated will try to increase his exercise to help focus their restless mind, continue to meet with the school counsellor to discuss feelings, and will try to practice positive self-talk when feelings of fear begin to become overwhelming. Client noted that he will check out the university website for supports. Client stated, “I think I will be able to follow these strategies and I will check out the supports in the next couple of weeks.” Nurse’s signature, designation ——————————————

 

APIE – Nutrition

Case summary: A 62-year-old client, identifies as male with pronouns of he/his, who is one month post cerebrovascular accident on a rehab unit. The client is on a thickened diet as a result of dysphagia.

Date (yyyy/mm/dd)

Time

Discipline

Notes 

2020/11/25

0930

nursing

A: Client stated “I’m getting use to eating my new diet and I’ve not choked since starting it.” Added thickener to client’s coffee. Client ate 90% of the meal. P: Will reinforce dysphagia eating techniques with client each day. I: Reviewed dysphagia eating techniques with the client: tilting chin down, small bites, placing food on unaffected side of mouth, eat slowly, and avoid talking while eating. Gave praise to client for eating independently and using correct eating techniques: swallowing twice after each mouthful, using a teaspoon portion size of food to unaffected side of mouth. E: No signs of aspiration. Client practiced head tilt and placement of food towards unaffected side. Documented meal intake. Ordered additional thickener package for client’s meal tray. Left phone message for speech language therapist and occupational therapist to re-assess client’s progress. Nurse’s signature, designation —

 

SOAP or SOAPIE – Elimination

Case summary: A 41-year-old client, identifies as female with pronouns she/her, on a postpartum unit 2 days after having a caesarean section (C/S). The client delivered a healthy 8lb baby.

Date (yyyy/mm/dd)

Time

Discipline

Notes 

2020/11/02

1030

nursing

S: Client commented feeling abdominal discomfort in left lower quadrant, rated 5/10, stating “I’m getting worried because I still have not had a bowel movement, it’s been four days” and is “worried it will hurt because of my hemorrhoids.” Client stated drinking 500cc of water today and eating about half of her meals. O: Bowel sounds audible in all four quadrants. Tympany predominates throughout, with slight dullness over LLQ. Abdomen firm and tender on touch. No nausea or vomiting. A: Constipation related to medication during C/S, limited mobility, low fibre diet and minimal water intake. P: Will assess client’s knowledge. I: Educated the client on the importance of increasing water intake to 6 to 8 glasses, eating the high fiber diet provided by the hospital, and walking around unit once an hour to assist with peristalsis and bowel movements. Demonstrated how to support incision area when getting up to go for a walk to decrease discomfort or pulling of incision. Provided teaching resources on postpartum constipation and caesarean sections. Provided client 500cc of water. Assisted client out of bed to go for a walk with family. E: Client drank water and stated will record fluid intake. Client had 400mg of Ibuprofen for abdominal discomfort. Will monitor diet and follow up to determine if constipation continues and further interventions are needed. Nurse’s signature, designation —

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Documentation in Nursing: 1st Canadian edition by Jennifer Lapum, Oona St-Amant, Charlene Ronquillo, Michelle Hughes, and Joy Garmaise-Yee is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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