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Notas de enfermería y ejemplos

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Definición, tipos de notas, fuente de información, objetivos, importancia, método SOAPIER, orden, color de tinta a escribir las notas, ejemplos de notas de: admisión, recibo, continuidad, transferencia DE, transferencia A, preparación para el SOP (cirugía), envío al SOP, recibo al SOP, trans...

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  • May 30, 2022
  • 34
  • 2021/2022
  • Class notes
  • Sofía valderrama
  • All classes
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NOTAS DE ENFERMERÍA
Según Manual de Procedimientos de Enfermería de Opal
Jones, Panamá, 2015.

,Diseñar correcta y estructuradamente las notas de
Enfermería.




Describir con terminología medica y de forma
completa cada característica que presente un
paciente.




Desarrollar diligentemente el método SOAPIER

, DEFINICIÓN DE NOTAS DE ENFERMERÍA


Es un registro escrito, el cual es redactado por la
enfermera o enfermero, acerca del paciente
tomando en cuenta todos los aspectos,
incluyendo la planeación y acciones realizadas
para mitigar o satisfacer las necesidades
biopsicosociales en el cliente.

, Nota de recibo
de paciente.
Nota de
Nota de continuidad de
admisión, los cuidados y/
transferido A, situación.
transferido De,
nota de egreso. Nota
retrospectiva.

Nota de envío y
recibo del salón
de operaciones,
de estudios
Nota de cierre especiales, de
de turno. traslado de
paciente a otra
unidad.
Nota de
defunción.

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