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This, in turn, is measured by the nursing staff and recorded prior to its disposal. If the patient is using a bedpan, the nursing staff member who empties the bedpan measures the urine prior to its disposal. Urinals usually contain measuring lines providing easy measurement. Urinals are also useful for measuring urine from other sources.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
For example, an "OB/GYN" section may be included, including language such as "G3P2, menarche at age 14, LMP 2 weeks ago, regular". family history (FH) "noncontributory" Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase ...
The recommended daily amount of drinking water for humans varies. [1] It depends on activity, age, health, and environment.In the United States, the Adequate Intake for total water, based on median intakes, is 4.0 litres (141 imp fl oz; 135 US fl oz) per day for males older than 18, and 3.0 litres (106 imp fl oz; 101 US fl oz) per day for females over 18; it assumes about 80% from drink and 20 ...
Measuring and recording intake and output (amount of food and drink consumed; amount of urine, stool, and vomit excreted) Emptying and recording the volume of surgical drains, such as Jackson-Pratt drains; Providing emotional and support services to patients, their families and other caregivers
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]