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ALL patient info needs to be completed on EACH page

lude in Must inc Multidisciplinaryonth Progress Record year -m format (D) - subjective and objective data relating to stated focus Data r) - day (3 lette(A) - actions and interventions Action Your Title/designation, Response (R) - client response to actions/interventions Use 2400 until you graduate. It Plan clock NO (P) - future actions/interventions then changes to LPN use of :
Date Time Discipline Focus

Name:
Hosp. #: Sex: DOB:

Hospital

All empty lines must be filled with a single STUDENT NAME & COHORT:line. NO empty lines (For marking purposes at the college) ______________________________

CLIENT CARE PROGRESS RECORD (Data/Action/Response/Plan)

2010May-10

1000 hr

SPN

Laceration Left Hand

In a few words summarize what your entry is talking about. Be exact and be brief!

D: Data What information have you gathered. What have you observed. Tell us about the situation--------------------------------------A: Action What did you do? Task you preformed? Did you ---------assess something ------------------------------------------------------------R: Response How did the patient/client react to what you did? Were they thankful? Angry? In pain? Did they say something? If yes quote what was said? -------------------------------------------------------P: Plan When will you follow-up with this issue? Action etc? Must be measureable ie: must have a timeline will reassess pain in 45 min ---------------------------------------------------------A. Williams SPN---The time is the time your are sitting down to chart. If an event occurred earlier (you You MUST sign every page and have a 1 hr time frame from every entry. If it continues onto the time the event occurred to a 2nd page you need to sign the the time you need to chart this bottom. Your nursing signature event). Late entries need to is: Your first initial . last name state this: D: Late entry at 0930hr............. You can not SPN . Always justified to the chart into the future. Event right of the page MUST occur before you chart it.

* Note:*

Must use BLACK ink Must be legible Legal Rule: If it is not charted/documented it is considered NOT DONE! Cover yourself legally. If you see, witness, hear smell something document it! It is better to chart too much vs too little. As time goes on you will be able to decipher what is pertinent and what is not. NO use of ABBREVIATIONS ALL words must be written in FULL Exception: TPR BP SPO2 (vital signs) TPR 36.8-72-12 BP- 110/68 SPo2-96% on room air

Name: Lucas, Kaleb

Hospital
Multidisciplinary Progress Record
Data Action (D) - subjective and objective data relating to stated focus (A) - actions and interventions

Hosp. #: 10009549210 Sex: Male DOB: 1989-AUG-02

STUDENT NAME & COHORT: ________________________________

Response (R) - client response to actions/interventions Plan (P) - future actions/interventions

Date

Time

Discipline

Focus

CLIENT CARE PROGRESS RECORD (Data/Action/Response/Plan)

2010May- 10

1000hr SPN

2010May- 10 2010May 10

1050hr SPN

1215hr SPN

2010May-10

1430hr SPN

Laceration D: Cut hand while slicing vegetables at home. 5 cm straight-------Left Hand incision to palm of left hand, draining bright red blood, no---------bruising, no swelling, no redness to wound edges.--------------------A: Cleansed wound with normal saline 0.9% wrapped with nonstick gauze------------------------------------------------------------------P: assess wound in 45 min time for bleeding---A. Williams SPN--Left Hand D: Dressing to Left hand dry and intact. No bleeding noted --------Dressing ----------------------------------------------A.Williams SPN----------Vital VS: or D: TPR 36.8-72-12 BP- 110/68 SPo2-96% on room air.----Signs Resting comfortably in bed with no signs of distress. ---------------P: Reassess VS in 2 hrs per protocol-----A. Williams SPN --------Vital D: TPR 36.9-64-10 BP: 108/70 SPo2-96% on room air.-------------Signs No signs of distress. Visiting with family---A. Williams SPN-------