Arthritis Care Record Contents

The core of arthritis care records is traceable information around four dimensions: changes in joint symptoms, effects of intervention measures, potential triggers, and risk warning signals. There is no mandatory unified standardized template. The core function is to help patients and medical staff identify the patterns of joint problems and adjust care and treatment plans. This is much more practical than vague subjective descriptions.

To be honest, last week Aunt Zhang, a 62-year-old patient with knee osteoarthritis, came for a follow-up consultation. I was particularly impressed by the crumpled little book she took out. It was either a ready-made nursing record form bought online, or an ordinary notepad that comes with reading glasses. It read crookedly, "Cool down on the 10th, go to the vegetable market." I walked on the field for 20 minutes and felt pain on the inside of my right knee. I put on the flurbiprofen gel patch that I prescribed last time. It felt better in half an hour. "I danced square dance for half an hour on the 15th, and my knee was stiff for 10 minutes when I woke up the next day." Even the corners of the remaining medicine bags were posted next to the corresponding dates, for fear that I would mix up the names of the medicines. This is the most practical home care record for ordinary patients, and it is more accurate than anything else.

There are actually two completely different views on the precision of records in the industry. One group is dominated by young rehabilitation practitioners. They advocate that the finer the better, it is best to be accurate to the number of steps, pain score (that is, 0 to 10 points, 0 is not painful at all, 10 is painful enough to roll), specific values ​​of joint mobility, and even what you ate that day and whether you stayed up late must be written down, so as to facilitate the investigation of all potential triggers.； The other group is mostly old doctors who have been in clinical practice for more than ten years. They feel that there is no need to put extra burden on patients. Joint pain is already worrying, and they have to count the time and steps every day, which makes them prone to anxiety. It is probably enough to write down "It hurts after walking too much today" and "I feel very stiff after cooling down". The key is to be able to see the trend. There is nothing wrong with either statement. Young patients have good memories and can remember more carefully. Elderly patients are dazzled and clumsy. Even drawing a little person and putting a cross in the painful area will work.

If it is a formal nursing record from a medical institution, the requirements will be more stringent. After all, traces must be left as a basis for diagnosis and treatment. For example, changes in inflammatory indicators such as C-reactive protein and erythrocyte sedimentation rate must be written clearly, whether non-steroidal anti-inflammatory drugs are used, whether there are any gastrointestinal adverse reactions after use, and rehabilitation training Degree of completion - For example, yesterday the patient performed 3 sets of quadriceps isometric contractions, 10 times each. Whether the pain worsened after completion, and whether there was any muscle soreness, these must be written clearly, otherwise the nurse will take over next time and will not know the progress of the previous care.

Don’t underestimate these fragmentary records. There was a 28-year-old patient with rheumatoid arthritis who always suffered from inexplicable pain in his knuckles at first. He couldn’t find any pattern. After recording it for a month, he discovered that he drank iced milk tea before each pain. At first, he thought it was a coincidence, but he verified it three times in a row. As long as he drank iced dairy products, his knuckles would definitely be swollen the next day. Later, after he stopped eating, the frequency of attacks dropped by half. There is also a young man who works in design. When he was first diagnosed, he was anxious and worked overtime every day. With the same inflammation level, he said that the pain was as high as 8. Later, he followed the doctor's advice and played low-intensity badminton twice a week. After he relaxed, the pain score dropped directly to 4. This is why many nursing records now add a mood note. Some studies say that anxiety can increase pain perception by 30%. This information is useless when viewed alone. Put together, you can find many hidden patterns.

Of course, you don’t have to write everything in it. There is still a controversial point about whether to record all your diet. One school of thought believes that except for gouty arthritis, which requires strict recording of purine intake, other types of arthritis have little connection with diet, so there is no need to restrict food.； The other group believes that many patients with autoimmune arthritis are indeed sensitive to specific foods, such as wheat and dairy products. There is no harm in writing it down and checking it slowly. There is no need to kill them all at once. Just try it yourself.

The most interesting nursing record I have ever seen was drawn by a 70-year-old patient who couldn't write, so he used colored pens to draw little figures in a small book. He painted red wherever it hurt, and painted it darker when the pain was severe. Next to it was a weather forecast sticker for the day. Dark clouds for rainy days and sun for sunny days. Although it was not "standard" at all, I knew at a glance that his pain was closely related to the weather. When adjusting the care plan, just increase the priority of keeping warm. To put it bluntly, the nursing record is never an assignment given to the doctor. It is your own joint instruction manual. The most useful content is what suits you.