Essay on Documentation Guidelines

805 Words Apr 22nd, 2014 4 Pages
Documentation Guidelines
Respiratory Problems
Respiratory rate, pattern, lung sounds, presence of cough or congestion, sputum, sternal retractions, unequal chest expansion, nasal flaring
Skin color: color of lips and nail beds, cyanosis
Use of O2, rate, delivery method, frequency of use,SPO2 (on RA on O2, after exertion, at rest) Weaning off O2
Use of Brochial Dialators and other respiratory medications, response to medications, Neb Tx, suctioning, IPPB
Activity tolerance
Causes of onset of SOB, how long does it take for relief use of high fowlers position
Goals set by resident and staff teaching performed, to resident and or family

Orthopedic surgery/fracture
ADL: describe what they cannot do
Assistance needed with what?
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what relieves it? (rest, O2, Nitro)
Signs and Symptoms of CHF: SOB, congestion, cough, tachycardia, weakness, edema, restlessness, anxiety (what causes it?)
Presence of EDEMA: where? measurement? if in legs elevate to reduce edema
Use of cardiac, blood thinners or diuretics and response to these medications
Skin color, color of lips, nailbeds (cyanosis)
Use of O2-if applicable pulse ox
Activity Tolerance: Ability to do ADL's how much? Ability to ambulate, How far? Do they need rest periods between tasks?
Goals set by the staff and resident
Teaching performed to resident and family

Urological
Urine (color, consistency, odor)
Urination (pain, burning, frequency, urgency, abdominal distention)
B/B retraining (continence, bladder control, awareness)
Catheter: suprapubic, indwelling, straight cath reason for catheter: retention, mobility, infection, skin, residual, nutrogenic
Fluid retention (wt increase, rales, edema, abd distention)

Pain Control
Types of pain: sharp, pounding, pressing, dull location Intensity number according to pain scale presence of pain: what time of day, durning what type of activity
Medication: How (PO, IV, IM, Supos) scheduled, PRN
Is medication effective? How long does it take to relieve the pain? How long does the relief last? How often is the pain medication given and/or requested in a shift?
Other Comfort measures provided: position change, massage, emotional support, diversion, decreased stimuli

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