Question

I am having trouble writing an evaluation note of my progress in clinical. Mid-semester, i was told by the professor i had trouble documenting but that my technique for physical assessment as well as the performance was improving fast. I need to incorporate tasks i have learned such as: a.m. care, oral care, bed bath, bed making, standard precaution, enteral feeding, help with feeding patients, incontinence care. Can you give me a short paragraph on how to write this?

Answer 1

1. To incorporate these tasks first a proper patient health assessment needs to be taken And proper documentation is required for any nursing care .
2. Be concise and cover what is to be done .
3. use passive voices when documenting .eg .Bed making done,oral care given
4. Always remember not to use” I “. Document as The client or The name of patient.
5. Documentation should be continuous and don’t leave any blank lines in between the documentation ,which paves way for others to write in between your documentation .
6. Charting is a very important as it is a legal document ,so Be careful while writing .
7. Always after providing care to patient document it and write the name and sign it .

Example of documentation :

Handover taken from  the night duty staff .The patient is not able to clean his mouth so oral care given .Oral cavity is normal .Bed care give ,Skin is intact .Sensation is intact to dull and sharp.Skin is dry.

Bed making done for the patient .There are no complaints .

Enteral feeds given ,Patient is able to tolerate well .Total total input and output needs to be documented .

Incontinence care .Patient is not able to void ,Physician advised catheterisation .Catheter inserted without any complications.URO bag connected and Output is monitored .