Nurse Note Sample (Page 3 of 8) in pdf

ProVation Medical Center

Patient Name: Martin, Rebecca

Patient ID: 56564567889

GI Nurse Note

Exam Date: 7/17/2013

Procedure(s):

Colonoscopy

Account#:

Level of Consciousness: Alert and Oriented x 4

Respiratory assessment: Breath sounds clear / equal

Skin assessment: Warm, Dry, Pink

Abdominal exam: Soft

IV started: YES

Attempts: 1

IV site: Right hand

Size: 18 gauge

IV solution: Saline Lock, Normal Saline (NS)

IV rate: TKO

Inserted by: MS

Time started: 07/18/2013 10:17

DISCHARGE

User:

msmith

Patient transferred by and report received from: jj

Siderails up on bed upon receipt of patient? YES

Transportation after procedure: YES

Driver location: Waiting Room

Driver's name/Relationship/Phone: John/husband/ 891-2712

May we share the results of the procedure with your driver?

YES

May we contact you tomorrow for a follow-up call?

YES

Level of Consciousness: Alert and Oriented x 4

Skin assessment: Warm, Dry, Pink

Abdominal exam: Soft

Does the patient currently have pain? NO

Bowel sounds: Present

Passing flatus? YES

DISCHARGE CRITERIA

Oxygen saturation on room air >=94% or equal to pre-sedation state?

YES

Able to ambulate independently (or at baseline)? YES

Able to take PO fluids? YES

IV discontinued: YES

IV site assessment: Dry, intact

IV removed by: MS

Time removed:

Amount IV fluids infused:

Comments:

Patient's valuables returned/reviewed? YES

Patient valuables returned to: Patient

Patient belongings removed/reviewed in Pre-Procedure

Patient Belongings Removed/Reviewed: YES

Patient items removed: Contact lenses, Hearing Aid

Patient belongings stored: Stored with patient

Patient meets discharge criteria as set by physician and approved by facility?

YES

Discharge instructions given to: Patient, Spouse

Discharged to: Home

Discharged via: Ambulatory

Discharged under the care of: Spouse

CARE PLANS

User:

jjones

PRE-PROCEDURE

1. Anxiety regarding impending procedure.

Actions: Assess patient for non-verbal clues, listen, clarify questions. Allow use of coping mechanisms. Refer to support

system.:

Outcomes: Expresses decreased anxiety and increased understanding of procedure:

Status: MET

2. Lack of understanding of procedure and medications.

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Nurse Note Sample Page 3

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