Documentation Tip of the Week
Hello, hello my nursing friends! So excited to bring you a new short series I like to call โ๐๐จ๐๐ฎ๐ฆ๐๐ง๐ญ๐๐ญ๐ข๐จ๐ง ๐๐ข๐ฉ ๐จ๐ ๐ญ๐ก๐ ๐๐๐๐คโ.
Iโm actually really loving this idea because not only will it help improve your charting skills but it will also better your assessment skills, which is SO VITAL in nursing.
With that said- todayโs Documentation Tip of the Week is on ๐๐ผ๐๐๐๐!
When charting about patient rashes you want to make sure you include:
๐ ๐๐จ๐๐๐ญ๐ข๐จ๐ง ๐จ๐ ๐๐๐ฌ๐ก. Where is it located? Is it localized to one area? Generalized? Or scattered throughout the body?
๐๐๐๐ฌ๐๐ซ๐ข๐ฉ๐ญ๐ข๐จ๐ง ๐จ๐ ๐๐๐ฌ๐ก. What does the rash look like? Is it a macular rash? papular? petechial rash? Is it raised or flat? What is its texture? Is it scab like, hives? or is it smooth? What color is it? Does it have an odor? Is there any swelling to rash or surrounding skin? Warm to touch?
๐๐๐ข๐ฌ๐๐ก๐๐ซ๐ ๐. Does the rash have any discharge? What color is it? Is it purulent, serosanguineous, sanguines or serous?
๐๐๐ซ๐ฎ๐ซ๐ข๐ญ๐ข๐ฌ. Does the rash itch?
๐๐๐ง๐ฌ๐๐ญ. When did the rash start?
๐๐๐๐๐ข๐๐๐ญ๐ข๐จ๐ง๐ฌ. Has the patient applied any medication? Has it improved or worsened the rash? Did the medication cause the rash?
๐๐๐ซ๐จ๐ ๐ซ๐๐ฌ๐ฌ๐ข๐จ๐ง ๐จ๐ ๐ซ๐๐ฌ๐ก. Has the rash gotten worse or better since it began. Has it gotten bigger? itchier? Changed colors? Has it began to ooze discharge? What aggravates the rash? What improves it?
๐๐๐ง๐ญ๐๐ซ๐ฏ๐๐ง๐ญ๐ข๐จ๐ง๐ฌ. Lastly, chart any interventions you performed as the nurse. Did you apply any prescribed ointments? Did you administer Benadryl or any other medication? Did you apply lotion? Did you clean the area and cover it? Or clean and leave it open to air?
โฆand donโt forget if you did perform an intervention to always ๐๐-๐ผ๐๐๐๐๐.
๐๐-๐๐ฌ๐ฌ๐๐ฌ๐ฌ๐ฆ๐๐ง๐ญ: How does the rash look after your intervention? Has it improved? Is it unchanged? Or maybe it appears more irritated? Re-assessment is key when carrying out any nursing intervention.
Great! Now that we know what needs to be charted – ๐๐กCan you name me a condition or disease that would have a rash as a symptom?
