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Documentation Guidelines

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Submitted By ppassehl
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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? Bathing, dressing, shaving, oral care, bed mobility, toileting (continent, incontinent, foley, bladder retraining, constipation. Transfer (lift 1-2 assist) Ambulation w/wo devices (walker, cane, w/c, distance in feet)
Attending PT, OT - frequency and time, check therapy progress notes and compare to progress on the unit (tolerance)
Incision: Intact, well approximated, sign of infection, treatment
Cast, splint care: neuro/ vascular checks
Presence of PAIN, if present what time of day, durning what activity, relief measures (medications/effectiveness)
Abductor pillow, hip precations, CPM, polar ice, ted hose, PAS stockings,
Goals set by resident and staff
Teaching performed to resident and or family, ability to learn

Diabetes
Doctor contacts, new orders
Dietary intake
Insulin Injections
Accu Checks, Labs
Diabetic teaching/response
Changes in LOC
Physical Limitations (ROM, amputation, arthritis, weakness, pain, blindness)
S/S Hyper/Hypoglycemia - HA, lethargy, weakness, polyuria, hunger, thirst
Skin Condition/Decubitus, wounds, infection, gangrenous sites, treatments

Cardiac Problems
VS
Presence of CP: type,

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