Question

Kindly summarize the followings;

1. Nursing Care Plan
2. Interdisciplinary Progress notes
3. ADL’s checklist/flow sheets
4. Vital sign flow sheet
5. Any Other Flowsheets
6. Kardex
7. Doctor’s orders

Answer 1

Nursing care plan-

Nursing care plan is the plan which is followed in a manner to take care of the patient.

It includes :

1.Diagnosis- list of health problems or conditions ,the patient is suffering from.

2.Goals and outcomes- In this,a proper goal is set for the short or long period.

3.Interventions /Nursing orders- In this,proper action or order is performed on the basis of diagnosis and goal set .It includes medications,vital signs checking,dosage and it's timings.

4.Evaluation-Depending upon the patient condition, evaluation is to find out whether there should be any change in nursing orders or not.

It contains all the information about the patient diagnosis,it's treatment and observations during the course of the patient's stay.

Interdisciplinary progress notes-

It is a note in which patient overall status and progress during the course of stay is recorded.These notes or medical records are signed by a physician that's why called as interdisciplinary progress notes.

These are prepared at the end of the shift and it contains all the information about the patient care on the day -to- day basis.

It is a mean of communication for the staff, patient family members and for the physician.i.e.,it provides all the information about the patients to anyone who is related to its care.

ADL checklist's/flowsheets-

ADL stands for activities of daily living.

It contains all the activities which person do on day -to- day basis. Proper record of all these activities in the form of list or flowsheet refer to as ADL checklist / flowsheet.

It includes-ADL function such as bathing, grooming,dressing, toileting,walking,eating,climbing,mouth care which is recorded in the form of list in accordance with the following criteria such as _ independent, dependent,needs help or cannot do.

Vital sign flowsheet- Vital signs are the important body functions which are recorded in the form of flowsheet.

Vital signs include weight,pulse,blood pressure, respiration, temperature etc.

These signs can be recorded or taken by hand or by equipment such as stethoscope, thermometer etc.

Any changes in vital signs is a sign of any changes in your body functions which is related to any health issue.

Whenever u are visiting to a hospital the first thing they do is to check and make proper vital sign flowsheet records.

kardex- kardex is a proper medical information system which is used by the nurse staff in the form of summary. It is used to transfer the information in a relevant manner to the other staff at the end of the shift change.

It includes information such as patient history, allergies its chief complaints, admitted reason and it's plan of care and medications.

Doctor orders- Orders which are given by the doctors to follow . These orders are valid only if it contains patient name, provider's name and signature,test order and reason for ordering the respective test.

Doctor orders are also refer to as medical prescription.It is proper advice by a doctor in the form of prescription when patient visit for any reason .

Related to medicine it includes date and time,patient's name and age,dosage with time ,route of administration etc.