No doubt completing these charting requirements are simplified for today's nurses, but these nursing notes provide lines and lines of very little of substance for doctors to read, read exactly the same from patient to patient (and hence are ignored) and once something is found (like the social issues noted), no description of the issue is provided.
"Patient Acceptance Note
Patient Direct Admit from home. Awake, Alert and Oriented. Patient oriented to BR/ER light, bed controls, TV/radio, patient education channel, telephone, bathroom, visiting hours, overnight stay and call light. Vital signs taken and recorded. Pain status assessed. See flow sheet for vital sign assessment.
Documented by: Sally Smith, RN 4/13/2008 at 5:59 PM."
Goal: PAIN CONTROLLED TO TOLERABLE LEVEL FOR PATIENT
NO C/O PAIN NOTED.
Problem: HIGH FALL RISK
Goal: FREE FROM ACCIDENTAL PHYSICAL INJURY RELATED TO FALL
BED LOCKED AND IN LOW POSITION. SIDE RAILS UP X 4, CALL LIGHT WITHIN REACH.
Goal: RESPIRATORY FUNCTION AT PATIENT'S BASELINE
NO REESPIRATORY DISTRESS NOTED.
Problem: HEMODYNAMIC STABILITY
Goal: PATIENT WILL MAINTAIN ADEQUATE TISSUE PERFUSION/HEMODYNAMIC STABILITY
VITAL SIGNS STABLE, AFEBRILE.
Problem: DEHYDRATION (NAUSEA, VOMITING, AND/OR DIARRHEA)
Goal: RESTORE/MAINTAIN FLUID BALANCE
+BS; CARDIAC DIET. NO NAUSEA/VOMITING NOTED.
Problem: EMOTIONAL STRESS
Goal: PATIENT WILL VERBALIZE LESS ANXIETY
PT HAS SOME FINANCIAL AND "HOME" AND FAMILY CONCERNS THAT SHE WOULD LIKE TO DISCUSS WITH SOCIAL WORK.
SOCIAL WORK CONSULTED."
Aspects of the new electronic medical record was not made for doctors or our patients, but clearly for quality assurance administrators.