Documentation

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Documentation
Hospital Corpsman Competency Training
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Objectives

• List the purpose of documenting patient care
• List types of patient care records and forms used
  by US Navy
• List the components and guidelines for writing
  SOAP notes and Nursing Notes
• List types of patient care information to be
  documented

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Purposes for documentation
of Patient care

• To provide a written account of Pts condition,
  treatments, progress, and response to care.
• Legal Record.
• Continuity of pt care

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Types of Patient Care Records

• Outpatient Record
• Inpatient Record
• Dental Record

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Patient Documentation Forms

• Chronological Record of Medical Care (SF 600)
• Nursing Notes (SF 510)
• Report of Medical History (DD Form 2807)
• Report of Medical Examination (DD Form 2808)

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Chronological Record of Medical Care

• Also known as SF 600
• Entries include the following
• Identification Data
• Date/Time
• Treating Organization/Facility
• Initial entry of care
• Discharge instructions and f/u instructions

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Proper documentation using the SF 600

• SF 600s are written using the SOAP note format.
• All initial entries must contain
• Chief complaint/hx of complaint
• Physical exam and clinical finding
• Analysis of clinical findings
• Tx accomplished/follow-up care, and medication.
• Each entry must be SIGNED!!!!!!!
• Remember if it is not signed, it didnt happen!!!

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What is a SOAP note?

• A SOAP note consists of a Subjective, Objective,
  Assessment, and Plan data.
• Subjective-
• What the pt is telling you
• use quotation marks when needed
• Avoid personal judgments
• Objective-
• The data you obtain from vital signs, physical
  exams, previous lab, and x-ray findings
• Assessment-
• What your diagnosis will be using the information
  gathered from the subjective and objective
• Plan-
• What your actions are going to be to help resolve
  medical condition.
• This can include medications (with instructions),
  labs, x-rays, pt education, f/u, consultations,
  ect.

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Proper documentation of a nursing note.

• Also referred to as an SF 510.
• Used for inpatient care
• Components of SF 510
• Date of entry
• Time of entry
• Observations
• Patient identification

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How to document using SF 510 format

• Written /filed in chronological order
• Format directed by local policy
• Each note signed by the person who wrote the
  note!!!
• Must use black ink
• Be brief
• DO NOT SKIP LINES!!!
• Use standard abbreviations
• If you do not know the correct abbreviation do
  not make up your own, just spell it out.
• Please be familiar with the commands standard
  abbreviation list. Some abbreviations are no
  longer used.
• If you make an error draw a single line through
  it and label error above with your initials,
  then continue note with correct info.

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Nursing Note Entries cont..

• Late nursing note
• Write late entry in AM/PM column followed by
  time and date of entry.
• A nursing note may be more than 1 page or less
  than 1 page.
• If your nursing note is less than 1 page, draw a
  line through empty spaces and label with no
  further entries

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Nursing note entries also include

• Mental status
• Orientation
• Observed mood/behavior
• Expressed concerns
• Physical assessment
• Abnormal VS (must be written in red ink and
  circled)
• Sensory/perceptual
• Neurological
• Skin
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Reports of discomfort
• Nursing care, txs, and procedures

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Medications that require a Nursing Note

• One time drug orders
• STAT Orders
• Pre-op medication/sedatives
• PRN Medications

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More Nursing Note information
that needs documentation

• Visits made by pertinent people or other hospital
  staff
• Patients response to meds
• Patients tolerance of procedures or txs
• Document name, rank of physician or nurse
  notified about abnormality or change in patients
  condition.
• This includes VS, physical /mental changes.
• This also includes positive changes.
• Safety measures
• Patient transportation
• All entries must be signed by person writing
  note(s).
• Remember if it isnt documented or signed it
  didnt happen, and that could spell DISASTER!!!!

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Report of Medical History DD Form 2807
This form has replaced the SF 93
Report of Medical Examination DD Form 2808
This form has replaced the SF 88
These forms are used to document Physicals for
enlistments, inductions, appt. for retentions,
and medical boards
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Any questions?