Nursing Documentation

klabofish@mwph.org

Hi lovely Peds CDI colleagues - 
I teach the nursing documentation segment of nursing orientation for my hospital. I have a PowerPoint that's been used for a million years. I'm wondering if any of you have PowerPoint presentations or other materials that you'd like to share r/t nursing documentation. 

Thanks!!
Kara 

evanspx@sutterhealth.org

 Also review the RN notes for GCS, NIH Stroke Scores, and Sepsis Alerts.  The RN notes recorded during the performance of cardiac catheterizations can also be useful as the RN may note runs of VT and other significant conditions that may support context for a query. 

Paul Evans, RHIA, CCDS

cmclose@saintfrancis.com

Hi Kara~ One thing I have noted a few times is that nursing usually documents clinical indicators of thrush. The doctor orders Nystatin but doesn't document what he/she is treating. I use the nursing assessments/progress notes in my physicians queries for a diagnosis related to clinical indicators & treatment. I find nursing documentation to be useful for CDI when querying the physician.

Claudine

jackietouch@aol.com

No Power Point to assist, but I will chime in with other helpful nursing documentation. Braden Scale for queries for functional quadriplegia, nursing admission assessment for degree of assistance needed with self-care, neuro and musculoskeletal assessments for indicators for quadriplegia/paraplegia, nursing documentation of provider notifications during emergencies for assessment findings to support queries. We also work with our MDs and CNSs during rounds to be sure that POA status is documented for any pressure ulcers documented by nursing on the admission assessment.

Jackie Touch

nsconey@gmail.com

This is a great opportunity.  Why are we not volunteering to write a powerpoint on a subject?  Some subjects would be one or two slides, others much longer.  Put out a topic.  I would be glad to write some.  My personal issue is BMI.  We need the height of the patient as well as the weight.