Nursing homes: categories of care and documentation.

CATEGORIES OF CARE

e.g: NH (nursing home) RC (residencial care).
-NH-1
-NH-PH
-RC-1
-RC-MP ( E )
-RC-PH ( E )

CHARTING AND DOCUMENTATION (nursing handover)

-Patient record:

-Care plan.
-Observation chart.

CARE PLAN (usual documents used).

• ADMISSION FORM.

• GETTING TO KNOW YOU FORM.
• SUMMARY OF DAILY LIVING ASSESSMENT (to identify care plans needs).

• MONTHLY WEIGHT, BLOOD PRESSURE, PULSE CHART.
• CLINICAL RISKS:

• DOCTOR ADVICE/VISITS.
• BLOOD  RESULTS.
• SPECIMEN  RESULTS.
• DENTIST / PODIATRY.
• OPTICIANS /PHYSIOTHERAPY/ DIETITIAN.
• ACCIDENTS/ INCIDENTS.
• HOSPITAL  ADMISSIONS.
• NAMED  WORKER REVIEWS / NAMED NURSE ( named nurse: nurse designated as being responsible for a patient's nursing care during a hospital stay and who is identified by name as such to the patient. The concept of the named nurse stresses the importance of continuity of care).
• RELATIVES: COMPLAINTS, COMPLIMENTS.

ABBREVIATIONS

BP: blood pressure (Reading: 120/80 - one hundred and twenty over/ on eighty).
P: pulse (Reading: 120 - one twenty).
c/o: complain of.
ADLs: activities of daily living.
Pt: patient.
obs: observations.