Question

The community health RN is caring for a family with a child who has significant developmental delays. The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy tube for her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive. During the hospital stay, the child’s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child’s weight and the parent’s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 50 pounds. The child’s current weight represents a 2-pound weight gain since hospital admission. The RN has chosen the NANDA-I nursing diagnosis of Ineffective health management r/t insufficient knowledge of expected growth and calorie requirements AEB parent states, “I thought the same tube feeding would be enough calories for a long time, I don’t know how to tell if the feeding should be adjusted.”

Create a narrative note to record this patient’s current health state

Compare and contrast the narrative format to other documentation formats (PIE, SOAP, SOAPIE, SOAPIER, Focus Charting, or FACT system)

Describe how an electronic health record (EHR) would be of benefit for the specific health care needs of this patient.

Answer 1

Narrative nursing notes

Documentation is an essential part of nursing care and the best communication tool used in a health care setting. Which provide rhythm to the recording and reporting process. Charting is an important aspect of legal and professional responsibility of a nurse. Documentation should move in pace with employer policies and legal system. Effective documentation adds to the accountability of practice and it aids in continuous evaluation and improvement.

Standards of documentation:

1. Client centered

2. Clear, comprehensive, concise

3. Relevance

4. Confidentiality

5. Accurate

6. Timely

7. Permanent

8. Accessible

Narrative note are the tradition way of nursing documentation. It includes the reporting of patient’s condition in chronologically and timely manner. They are also known as progress notes or nurse’s notes. It has a narration about patient condition within a specific time frame. Approved abbreviations can be used in this. Narrative note are a little time consuming and illegible handwriting of the writer may interfere its accuracy.

PIE documentation : Problem, Intervention, Evaluation documentation . Nursing process forms the underline frame work of PIE documentation. In this the nurse uses the questions like What is the patients problem? What is the nursing interventions? Were they effective?

SOAP SOAPIE or SOAPIER :These are problem oriented approaches of documentation methods which include the nursing process .

Nurse identifies the problems and follows the nursing process.

S = subjective data

O = objective data

A = assessment

P = plan

I = intervention

E = evaluation

R = revision

Focus Charting:In focus charting nurse identifies a “focus” which can be a patients behavior, response or problem and plans according to that and document it.

FACT system: It can make use of the flow sheets, assessment, concise and timely entries.

Nursing Progress note

Patient Details:

Brief History:

Discharged 2 days ago after a 5-day hospitalization for failure to thrive

Date and Time:

Problem: Ineffective health management r/t insufficient knowledge of expected growth and calorie requirements

Nurses Notes: Child is 9 years old but the developmental level is of 6 month old infant. Patient can move her extremities spontaneously , lift her head up and cry out rarely. Patient is receiving medications via gastrostomy tube and feeding via pump. She was admitted to hospital for failure to thrive and discharged from the hospital before two days, her feeding pump adjusted from that and she gained 2 pounds of weight thereafter. Current weight is 50 pounds.

Mother states that, “I thought the same tube feeding would be enough calories for a long time, I don’t know how to tell if the feeding should be adjusted.” Which shows insufficient knowledge regarding health management related to insufficient knowledge of expected growth and calorie requirements.

Mother has given health education about the nutritional requirement of the child and about the disease condition.

Electronic health Records

EHR is the form of documenting patient’s data electronically. Which can be entered and retrieved easily. It speeds up the documentation and improves accuracy. Strict measures should be taken to maintain confidentiality. HER helps in standardization of care and in cooperates with the standard nursing process. Community based health care services get more advantages from EHR. HER helps the updating of information easily, like change in prescription.