this is about getting some health information about the patient.. but since i’m still a student and it’s my first tme to be working on this.. i don’t have any idea. there’s a lot to be asked to the patient but i’m not sure of how to put it in the narrative way.. i need S.O.S… thanks a lot again…
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umm if you are a student how come this wasn’t explained to you?
I’m not sure exactly what is needed, but if it’s a report that you’re talking about, maybe something like:
Mr. Smith said that both his parents had died of heart disease. When I questioned him further, he explained that his mother had died of an MI, while his father had congestive heart failure.
One of his brothers had cancer, but is currently in remission. He has two sisters, neither of whom has had any sign of cancer or heart disease.
Something like that?
The most common nursing note is in the SOAP form: Subjective, Objective, Assessment, Plan.
Thus:
S: Ms. Wilson complains of earache in Right ear.
O: Temp 99.8 oral. Pt. moaning and rates pain as a 7 on 1-10 scale.
A: Pt. in distress
P: Schedule examination with Dr. Feder ASP. Will continue to monitor pt. for signs/symptoms of infection and distress.
Signed: Me, RN
OK…Go in this order…
Name
Age
DOB
Were they a full term/premie baby
Any childhood illness’s/surgeries
Female/Onset of Menstruation/Pregnancies(term or early or problems with pregnancy) /Miscarriages/Menopause
Any Adult illness’s
Any Adult surgeries
Medical allergies
Medication they are on currently
Family History (Mother, Father, Siblings)
Why are they being hospitalized
Plan of care for the patient in the hospital and plan for dismissal
So lets pretend
Jo Smith is a 25 year old female born April 1, 1981. As a child she had the normal childhood illness’s including chickenpox and german measles. She no injuries or illness’s requiring hospitalization. She started her menstruation at age of 11 and had her first pregnancy at age 22. She carried a term infant and delivered at 39 weeks a healthy baby girl. She had no complications with the pregnancy or delivery. She is still menstruating and has normal 3-5 day periods and her cycle is around 29 days. She has had no serious illness or injury requiring hospitalization. Her parents and siblings ( 2 sisters and 1 brother) are alive. She has cancer and heart disease history with both parents. The patient was hospitalized 2 days ago when she fell and fractured her right tibia/fibula. She is currently on bedrest with a short leg cast on with elevation. She is on Demerol 75mg IM for pain every 4-6 hours, Phenergan 25mg IM every 4-6 hours for nausea, Ibupofen 800mg po for less pain. She is not on any medications at home. Her skin integrety and sensation including color and warm are being checked every 2 hours and documented. Her toes are pink and mobile and she has good sensation. She is getting walker training by physical therepy at the bedside. Her physician is planning for her release in the next several days. The physician and nursing staff is working with the patient to involve her in her care and care at home.
Now this may be way too much but feel free to adapt it to what you need..it kind of gives you the flow of things..it also gives a list of what to ask (make your own list and then when you set down with the patient you can just fill in the blanks..I hope this helped..I have done these so many times in school and still do them at work..good luck..
You will find your answer here http://cnhs.gmu.edu/writing/types.html
Good luck in Nursing school