Nursing notes no problems and feels
Posted By: pc on 2008-02-13
In Reply to: feel or feels sm - Jan
Subject: Nursing notes no problems and feels
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Nursing feel or feels? that the patient has been doing well. TIA
Subject: Nursing feel or feels? that the patient has been doing well. TIA
Nurses' notes or nurse's notes or nurses notes?
Subject: Nurses' notes or nurse's notes or nurses notes?
I am so confused on this one. I have typed it several different ways over the years. Do I really need to put any apostrophe in there at all? Thanks!
alm is right, skilled nursing facility, as in a short stay in a skilled nursing facility
Subject: alm is right, skilled nursing facility, as in a short stay in a skilled nursing facility
Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
feels
Subject: feels
/
Anyone heard of this, MAR from the nursing SM
Subject: Anyone heard of this, MAR from the nursing SM
home, this is in the medication part of PE. Patient admitted from the nursing home, and I assume this is a nickname for med sheet. thanks
do not know how to spell... he just feels s/l bla-za about everything. thank you
Subject: do not know how to spell... he just feels s/l bla-za about everything. thank you
which she feels ARE associated with...my only correction.
Subject: which she feels ARE associated with...my only correction.
nm
feel or feels sm
Subject: feel or feels sm
Nursing notes no new problems or complaints and feel/feels the
patient has been doing quite well. I'm thinking the correct word is
"feel" but want to verify.
Yes. He just means she feels the
Subject: Yes. He just means she feels the
irregular heartbeat. I would make it all one sentence though:
Irregular heart beat, more subjective and probably stress related, as she does exercise well.
It looks good to me with feels
Subject: It looks good to me with feels
It is probably SNF (skilled nursing facility).
Subject: It is probably SNF (skilled nursing facility).
nm
Nursing school teaches it as pus-like.
Subject: Nursing school teaches it as pus-like.
I am an LPN turned MT (did take classes). In nursing school the very first thing we learned about charting, doing admission assessments, etc. was DO NOT use the word pussy. In the medical profession it is not acceptable, even though doctors do dictate it. Nurses are taught to use pus-like. In addition to that and what the BOS says, as well as for the state of professionalism, I always use pus-like and have never had it corrected.
patient feels his ears need to pop
Subject: patient feels his ears need to pop
the patient feels his ears need to pop. He was given some (here goes....s/l med in LA). I don't know if he was given some Med in LA, CA, or if the medication is called Med-N-LA. Anyone have any ideas?
Thanks!! Today feels like Monday for me!!
Subject: Thanks!! Today feels like Monday for me!!
She feels better although her s/l "sats" are 88, but that my be normal for her. nm
Subject: She feels better although her s/l "sats" are 88, but that my be normal for her. nm
Hoyer is correct. I know, my Dad uses one in the nursing home. nm
Subject: Hoyer is correct. I know, my Dad uses one in the nursing home. nm
.
That's how we were told to remember it as nursing students
Subject: That's how we were told to remember it as nursing students
s
He will have Home Health Nursing. A s/l precaretender is following him. TIA!
Subject: He will have Home Health Nursing. A s/l precaretender is following him. TIA!
everyday lately feels like Monday working for THEM
Subject: everyday lately feels like Monday working for THEM
Patient will have a s/l *blow* tube for nursing light. Please sm..
Subject: Patient will have a s/l *blow* tube for nursing light. Please sm..
Also s/l *blue* tube. Thinks.
Whoa! Flashback to my hospital nursing days. :) Thx for the
Subject: Whoa! Flashback to my hospital nursing days. :) Thx for the
s
He means "SNF" (skilled nursing facility) .nm
Subject: He means "SNF" (skilled nursing facility) .nm
SNIF - skilled nursing inpatient facility. =) NM
Subject: SNIF - skilled nursing inpatient facility. =) NM
x
I have always used "skilled nursing facility." I have never seen SNiF as an abbreviation nor
Subject: I have always used "skilled nursing facility." I have never seen SNiF as an abbreviation nor
have I ever typed "skilled nursing inpatient facility." And I've been at this a long time.
patient says her lungs feels _____(natty)?
Subject: patient says her lungs feels _____(natty)?
x
Thank you maj, I know what it feels like to be stuck and how great it is when this board has helped
Subject: Thank you maj, I know what it feels like to be stuck and how great it is when this board has helped me "fill in the blank" without sending that report out looking like swisscheese.
perivascular space?... PS Hope your baby feels better!..nm
Subject: perivascular space?... PS Hope your baby feels better!..nm
x
Nursing home patient on S/L NR with diuretic and Catapres patch sm
Subject: Nursing home patient on S/L NR with diuretic and Catapres patch sm
Make any sense, also receiving Norvasc for elevated BP. Thanks
Comfort?? x-rays were performed on nursing home pt after fall
Subject: Comfort?? x-rays were performed on nursing home pt after fall
I say "feels" because nursing is considered a single unit in this context. nm
Subject: I say "feels" because nursing is considered a single unit in this context. nm
x
Pt with dementia in nursing home with s/l "fa (with the a being like in "at") score of 6 &#
Subject: Pt with dementia in nursing home with s/l "fa (with the a being like in "at") score of 6 "little e".
Since going back to work, she feels like she does get a "REBRIEF" from caretaking responsibil
Subject: Since going back to work, she feels like she does get a "REBRIEF" from caretaking responsibilities.
The patient's "templin" moved posteriorly and he feels like it is falling out
Subject: The patient's "templin" moved posteriorly and he feels like it is falling out
LOL, perhaps the patient feels very "negative" about females? These docs can make you smile,
Subject: LOL, perhaps the patient feels very "negative" about females? These docs can make you smile, huh? nm
nm
Early satiety? It means stomach feels full very quickly.....sm
Subject: Early satiety? It means stomach feels full very quickly.....sm
sometimes sign of GI problems, like delayed gastric emptying, etc. Does it sound like that?
op notes
Here is a list from my favorites. Hope they are a little bit helpful. I think they are all still good sites.
Op note sites:
http://www.mt-stuff.com/ent.html
http://mtdesk.com/gen.shtml
http://www.medical-library.org/journals2a/tubal_ligation.htm
http://www.mtdaily.com/samples.html
http://www.nezhat.com/oplap_abst.htm
http://www-personal.umich.edu/~aalin/vitalsigns/contentappendix/cntappsamplenotes.html
op notes
Subject: op notes
I have never encountered such a rule. I don't generally listen to where the dictators want their paragraphs, though. They usually put in way too many. I start a new paragraph after the prep and drape description and a I start a new paragraph for the closing of the wounds. I add new paragraphs when the surgeon is addressing a new area. That's just my style of transcribing. I'm not saying it's the right way to do it. It just makes sense to me and I would think it is easier to read and comprehend that way.
take notes!
Subject: take notes!
Whenever I have to spend a lot of time looking something up, I make sure to write it down. It's worth it.
I don't do op notes! LOL
Subject: I don't do op notes! LOL
thanks - i usually do ER notes so not familiar with that!
Subject: thanks - i usually do ER notes so not familiar with that!
Resources for OP notes?
Subject: Resources for OP notes?
Is there anyone here who does operative notes and gynecology notes who could give me some websites to use for resources? I am on an OB/GYN account and have operative notes. I have trouble sometimes with the specific surgical instrument names and would greatly appreciate any help. Thanks in advance.
Resources for OP notes?
Subject: Resources for OP notes?
My suggestion would be to purchase (if you do not already have)OB/GYN, equipment and surgical word books (Steadman's) my choice and you would be equipped to better perform your job.
OP notes resources
Subject: OP notes resources
I would do that but we are on a tight budget as we just bought a house and are getting in married in september.
Paragraphs in Op notes
Subject: Paragraphs in Op notes
I have noticed that when I transcribe an Op note as the dictator dictates it, starting a new paragraph as dictated...that QA always removes the spacing between the paragraphs.
Is there some rule in transcription that you don't break an op note into paragraphs? The client profile does not say anything about this.
SOAP notes
Subject: SOAP notes
Was wondering if there are any websites out there that gives sample reports for SOAP notes. Just trying to figure out which is the best way to do it with paragraphs between each heading or all scrunched together. Just want to see what is done more of. I realize it might depend on the clinic, dr, hospital, etc, but just want to get an idea.
Thanks Carla
Thanks so much! I'm taking notes!
Subject: Thanks so much! I'm taking notes!
SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
I have parascapular in my notes.
Subject: I have parascapular in my notes.
Think just nurses notes. IMO. nm
Subject: Think just nurses notes. IMO. nm
Nurse's notes..
Subject: Nurse's notes..
An apostrophe shows ownership. :-)
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