Arthritis Care Record Contents

Objective symptom records, intervention traces, efficacy feedback tracking, and risk warning annotations, whether it is a medical institution’s standardized nursing file or a patient’s home self-monitoring record, it is enough to write these four types of information clearly.

Last week, I was sorting out the chronic disease files at the community health service center and came across the records of Aunt Zhang, a 62-year-old patient with knee osteoarthritis. The two contents were very typical when compared together: one was written by herself at home, "On March 28, I went downstairs to throw out the garbage. My left knee hurt badly. I rubbed it for a long time and it felt better." The other was the record that our follow-up nurse followed up on the same day, "March 29 On the day of the follow-up visit, I found tenderness on the inner side of my left knee, NRS pain score of 5, no redness and swelling, and morning stiffness <10 minutes. Pain was induced when I squatted down to pick up garbage yesterday. I gave her local hot compress and flurbiprofen gel patch for external use. She was told to avoid squatting and climbing stairs. I will follow up in 3 days." Anyone with a discerning eye can see at a glance that the latter information is really effective content that can be used to adjust the nursing plan.

The industry’s current requirements for symptom recording are not completely unified. The evidence-based nursing team advocates that quantitative indicators such as pain score, specific location, triggering factors, and whether it is accompanied by redness, swelling, and morning stiffness must be clearly stated. However, our colleagues in the elderly group often say that when you encounter an elderly person with a poor memory and mild cognitive deterioration, you can’t tell them exactly how many points they would give. It is better to remember clearly “It hurts too much to walk today” or “It hurts but I bought groceries as usual” and then corresponds to the facial expression pain scale grading above, which is more accurate. Both methods are not wrong. The core depends on who the record is for.

Oh, by the way, never write vague descriptions such as "uncomfortable joints" or "a little pain". Such records are written in vain. There was a patient with gouty arthritis who wrote at home that "his feet hurt a little bit." We didn't take it seriously during the follow-up visit. Two days later, when he came to see the doctor, his feet were so swollen that he couldn't wear shoes, and his uric acid soared to 620 μmol/L. If the record at that time had mentioned "redness, swelling, heat, and pain that you can't touch", we would have intervened in advance, and he would not have suffered this crime.

There are no fixed standards for leaving traces of intervention measures. Whether you applied plaster, took painkillers, or did 10 minutes of rehabilitation training, just write it down truthfully. Don’t take it too much trouble. Nurses in the rehabilitation department will require the number of sets of rehabilitation exercises, the number of times for each set, and the amount of weight to be clearly written down, so that it is easier to follow up on exercise tolerance. However, as we do home care, we usually just ask the patients to record "I did 15 minutes of silent squats today, no pain." If the requirements are too detailed, many people will give up after just two days of recording, and the gain outweighs the gain.

Efficacy feedback is the core basis for doctors to adjust treatment plans. I have encountered many patients who frowned during follow-up visits and said, "I took the medicine you prescribed and it didn't work." Then I asked how many days they took it, how much they took each time, and whether they felt no better or less painful after taking it. They couldn't tell. If there were continuous records, there would be no need to bother. The most attentive patient I have ever seen. She even wrote down details such as "the pain is 2 minutes worse than usual on cloudy days" and "it hurts the next day after square dancing." In the end, the doctor adjusted the medication time according to her situation and helped her change her exercise methods. Most of the pain that had troubled her for three years was relieved.

The content of the risk warning must be placed in the most conspicuous position of the record. Whether there is a history of drug allergies, whether there has been joint effusion before, and whether there are underlying diseases such as diabetes/osteoporosis, etc., must be clearly marked. I have been in a trap before. There was a patient who was allergic to sulfa drugs. The previous record was hidden on the last page of the file. The new nurse prescribed celecoxib for him. After taking it, he developed a rash. Although he was fine afterwards, he also broke out in a cold sweat. From then on, all our arthritis care records and allergy history were written in red pen on the first line.

In fact, to put it bluntly, nursing records are not something for leaders to check and deal with errands, but a "health diary" that follows the patient. There is no need to pursue how beautiful the writing is or how it conforms to the so-called norms. As long as the information is factual and accurate enough and can help the patient suffer less, it is a good record.