NURSENOTES.US
An assistant for the construction of nursing notes in a very easy way.
Choose the forms
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Fill out the forms
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Note completed
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About
A basic purpose of the nursing documentation is the creation of a data base in which the patients’ files are included. The patient’s file is kept for many reasons, from which the most important ones are: communication, creation of the patient care plan, control of the health organizations, research, education, compensation and legal documentation.
There are several types of nursing documentation (flow sheets, narrative, source-oriented, problem-oriented (SOAP and PIE), focus (DAR), charting by exception (CBE), critical pathways, computerized). Also, there are several scenarios where the documentation is carried out: primary, secondary and tertiary level of health care.
Nursenotes.us is intended to be a simple and easy-to-use tool for building an important variety of nursing notes. It is important to note that this tool is only an aid to the nursing professional to speed up the work; that the most important thing is a thorough knowledge of nursing skills.
In a first attempt, we presented simple forms of the most common of the nursing activity, in a primary care environment, in home care. Later we will add other forms, with greater complexity and in other setting, based on the needs that you express to us.
Example
WOUND CARE SKILL VISIT
Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. SN removed dressing from right arm. No s/s of secondary infection, surrounding skin intact. SN performed wound care to right arm as follows: cleanse with N/S, pat dry, apply triple antibiotic, DSD, and secure with tape, twice times a week. Procedures were done following aseptic techniques and universal precautions were used. Patient tolerated procedure well without complaint or complications. Patient is incapable of perform wound care due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN educated Pt/ CG how prevent pressure ulcers: Provide appropriate support surface, reposition every two hours in bed, off-load heels (use pillows or positioning boot), reposition every hour when in chair, use pillow between legs for side lying, do not position directly on trochanter, do not use doughnut-type devices. Patient/caregiver verbalized understanding teaching.
More forms available to be used...
We offer templates based on daily nursing practice. However, you must complete the notes based on nursing policy and procedure manual of your Health Care Organization.
Jorge Montero
