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Documentation Guidelines Essay

816 words - 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 ...view middle of the document...

Chart according to the care plan.

Cerebrovascular Accident
LOC
Presence of paralysis or weakness
Neuro-checks: pupil reaction to light, hand graps, lower extremity strength, mobility/range of motion, object-hand coordination, gait (shuffling, buckling knees, leaning)
VS: BP if CVA was caused by hypertension
Communication Skills: Is resident aphasic? If so, how does he/she communicate? Use of non verbal gestures/cues
What rehabilitation therapies is the resident attending- physical, occupational, speech?
ADL's: Independent, supervision, assistance (1or2) for...

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