Charting: a really effortless! Pocket Guide offers time-starved nurses with crucial documentation directions in a streamlined, bulleted layout, with illustrations, emblems, and different Incredibly Easy! positive factors. The ebook is comfortably pocket sized for fast reference each time and anywhere.
The first part stories the fundamentals of charting, together with forms of files, dos and dont's, and present HIPAA and JCAHO laws. the second one part, alphabetically equipped, offers 1000s of examples and guidance for safely charting daily occurrences. emblems comprise Help Desk most sensible practices counsel; Form Fitting accomplished kinds that exemplify top-notch documentation; Making a Case documentation-related lawsuits; and Memory Jogger mnemonics.
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Extra resources for Charting: An Incredibly Easy! Pocket Guide
V. fluids? _________________________ fusion urine specimen No Blood warmed? ____________________________ from patient. 7. Record information Specimen collection as indicated below. No Blood: Difficulty collecting? ___________________ 8. V. M. labels to the blood bank with this form Monica Belinski, RN 2/13/06 completed. V. solutions, and all related forms and labels) to the blood bank. • Complete a transfusion reaction report, according to facility policy, and send it to the blood bank. • Document your follow-up care.
_________________ Dr. Barbera Other personnel_________________ B. Russo, RT The write stuff • Document the date and time the code was called. • Record the patient’s name, location of the code, the person who discovered the patient, the patient’s condition, and whether the arrest was witnessed or unwitnessed. • Record the name of the practitioner notified, time of notification, and names of other members who participated in the code. • On the code record, note the exact time for each code intervention and include: – vital signs – heart rhythm – laboratory results (such as arterial blood gas or electrolyte levels) – treatment given (such as CPR, defibrillation, or cardioversion) – drugs given (name, dosage, and route) – procedures performed (such as intubation, transvenous pacemaker insertion, and central line insertion) – patient response.
Document dressing changes and site care performed. • Document recalibration of the equipment. qxp 3/15/12 10:51 AM Page 34 34 A • Include the amount of flush solution infused in your note as well as on the intake and output record. Bl 09/06/06 0500 BP 90/60, MAP 70, via ø radial arterial line, with pt. at 45-degree angle. Cuff BP 86/58. Monitor shows normal arterial waveform. See strip mounted below. ø hand warm, pink, with capillary refill less than 3 sec. Pt. able to move fingers of ø hand, no c/o pain, able to feel light touch.