Question

To document "Subjective [DD*CC to the HP building to "see Vip MPH SAM doing ROS summary"

example here is = HPI documenting
Step 1: select HPI
Step 2: HPI form apears for the CC filled by nurse[e.g abd.Pain here];
Step 3: click the add HPI option if you need other
Step 4: if you are not satisfied by the form "add Narriative and document the HPI"

Answer 1

Symptoms are subjective experiences that cannot be measured objectively but are crucial for diagnosis. Nurses document these symptoms, use scales like the Wong-Baker Faces pain-rating scale for quantification, and ensure accuracy in medical records and procedure preparations.

Step-by-step explanation:

When documenting a patient's symptoms, it's important to understand that these are subjective experiences reported by the patient, and can include sensations such as nausea, loss of appetite, and pain. Clinicians often use scales like the Wong-Baker Faces pain-rating scale to put a quantitative value on these subjective symptoms. In a healthcare setting, nurses play a crucial role in this documentation process, ensuring accuracy and completeness, such as verifying that procedure names are recorded correctly and that counts of items like needles and sponges are complete. Additionally, labeling of specimens must be confirmed for accuracy, and any equipment issues should be addressed.