How to Document

Hi. I am a new lvn and currently working in SNF...Can someone please teach me how document. ei.

-Patient came back from the hospital and she show me and told me that she has a small wound because she fell while she was walking. ( i dont know how i would document her small wound )

- she also had a swollen wrist

-she also had rashes all over her leg. NKA and she doesnt know the reasons.

what would you do or be your INTERVENTION and how would you DOCUMENT this please could someone help me .... Thank you in advance.
I would document on the new admit assessment that pt. has a (red area, scratch, bruise) on (For example) left hip that measures 2 c.m. by 6 c.m. Pt. states that injury is the result of a fall while walking at Community Hospital. Left wrist is swollen (measure circumference). Pt does / does not complain of pain / stiffness at this time. (Document pain interventions if c/o pain). Red rash of unknown origin on Right leg from 2 cm above ankle to 3cm below knee. Pt. does/does not complain of itching. Washed with warm soapy water, rinsed with warm water, and applied anti itch cream (or what the doctor ordered). Where I work, I'd call in wound care and back it up with pictures - and I'd document that referral. But that's here.

You need to bring these questions to your supervisor. It is part of their job to bring you up to speed in matters like this.

P I EP = problem: describe all aspects eg what patient c/o, what you see, what you've found (data)I = intervention: What you did in responseE = evaluation: How did things end up? (new data) Is problem resolved? Does patient state or show improvement? or no?

thanks for the replied. its very helpful. If the patient has a swollen wrist or edema. what would be your intervetion or what would you do? she doesnt complain of any pain it just swollen. thank you so much

If patient returned from hospital with swollen wrist s/p reported fall in hospital. I would look for any documentation of intervention at hospital (e.g. X-ray report) and I would notify MD in case he wanted to order a portable x-ray etc. and the patient's responsible party inform them of fall and what was being done. ALWAYS document patient's exact words and what you did otherwise days from now when pt begins to c/o pain and is bruised and swollen there will be an investigation for "injuries of unknown origin"

Quote from foreverhopefulthanks for the replied. its very helpful. If the patient has a swollen wrist or edema. what would be your intervetion or what would you do? she doesnt complain of any pain it just swollen. thank you so much

YOu should have forms to document these area. Don't you have an admit skin assessment? After doing those, I would call the RN or if the LPNs do it in your building, call the doc and let them know. Do you have any skin care protocols to uses? If you don't have those forms or protocols at the very least must make a nurses note.

Quote from ivanaBEEaRNRemeber heat and ice can be used as a non pharmacological pain reliver