78 y/o Pt found in bed A&O. Vitals noted above,lung sounds clear equal bilaterally, normal chest rise & fall with normal tidal volume. Skin color normal and warm, cap refill normal. Eyes PEARL, neck midline and intact. No jvd. Chest,pelvis and legs intact. Pt denies c/p & sob.
Points to consider from your report above....
1. A&O To WHAT? Person, time, place, situation...? Should be A&O x 4....if it is A&O x anything less, then you need to list which specifically
2. "Vitals noted above" is redundant. Avoid filling your page with fluff.
3. Lungs C/E Bilaterally...ok, what about posterior? What about axillary? If you are going to document lung sounds and represent you are trained in them, then assess all of them and note it. This is good training in many aspects...you are exposed to all kinds of different sounds, you may see changes in your regulars, you may become extremely proficient at identifying sounds and in the future when you advance to ALS level, you will be comfortable. Assessing all lung sounds also affords you opportunity to further interact with a patient, taking charge, giving instructions in a competent and confident manner. This will boost your personal skills tremendously.
4. What about abdomen? You make no mention of it. Is it distended, is it soft, is there any pain, is it rigid, bloated? Bowel sounds? practice finding those and what they sound like....what else are you going to do during these transports. take advantage of being a better clinician.
5. "Normal chest rise and fall and normal tidal volume"...did you measure the patient's tidal volume? Are you sure it is normal? How would you prove it to me that it was normal? And what is the normal you speak of...quantify it how? Does the patient get winded with exertion or talking? Fatigued?
6.Skin color..."Normal and warm" What does this mean? What color is the skin? Is it wet or dry? Any yellowing? What about the nail beds? Any discoloration or light blues showing chronic deficiencies?
7. Cap refill....again with the "normal"....we know what a normal cap refill should be...but what was it exactly when you checked it. Sure, less than 3 secs is normal but what if hers returned at 1 sec....getting specific truly validates that you assessed the patient and did not just pencil whip the report which is common with inter facility transports. Provide date to support your words and your use of "normal".
8. Eyes Pearl...were they? Did you truly assess them or another sounds good to note comment? What was the pupil size? Any cataracts....this will distort your use of PEARL...I have QA'd many reports where that term was used when the patient had nothing but cataracts....or cataract surgery which will make the pupils unequal.
9. "Neck Midline and intact" I certainly hope the neck is midline and intact, otherwise we got a serious issue here!
This little piece you are trying to document would be "Trachea is midline, no shift noted" or something like that. This is also where you would note negative JVD as you did.
10. I am very glad that the chest, pelvis and legs are "intact" as well...seems you have a complete human on your hands. (Sorry I like sarcasm) You have already noted the lung sounds so what exactly are you wanting to document about the chest? Whatever it is, intact will not suffice in a proper SOAP.
Pelvis...if you want to assess the pelvis (as in a trauma assessment) you will note it is stable.
Legs...again, you cannot just put intact. It tells me nothing other than the assumption that there are two of them and no amputations have occurred yet. You need to note their color, any skin mottling, any edema...if there is edema (pitting)...how long is it pitting for? If they have slippers on or socks and you want to be thorough, take a look at their feet.
Remember what their underlying conditions are and where problems will first start...the feet! You may see early signs of necrosis, poor perfusion, color changes, etc. Remember they do not see their doctor weekly and I am willing to bet hardly anyone ever sees their feet. If this is a regular, you could catch something early on and bring it to someone's attention. Are they lacking in nail care, do they have fungal infections?
11. "Pt denies CP and SOB"...yes another lovely documentation catch all phrase. Normally this is one of your more important pertinent negatives and is documented right up front as that is when you would have typically asked and assessed for. Noting the patient does not have these things is fine, but there are a million other conditions you did not note as the patient not having...why? See my point? I am not going to dissuade you from documenting these things, just want you to be more aware of why you are writing them. Sometimes it is good practice to spell things out completely as well. I know there is an accepted list of abbreviations but it does not mean you have to absolutely use them....I could have read this as the patient denies cerebral palsy and son of a bee-otch.
I applaud you on asking questions and trying to improve your documentation and assessment skills. Take above advice for whatever it is worth, along with everyone else and get amongst it!
