Charting Tips

General/Pain

• Pt rec’d resting in bed comfortably, no sign of distress noted, V/S stable, CBG____, Pt states
he/she slept well
• Pt rates pain 4/10 in abdomen, pt states pain to be sharp/dull/intense, analgesic given
PO/IV/IM/SC, continue to monitor pain control
• no voiced concerns @ present, continue to monitor

Safety

• Call bell within reach, side rails up and bed in lowest position
• Pt understands to call for help when getting up
• Pt understands reasons for isolation, wearing gown/glove/mask

Neurological

• Pt is A+Ox3 (time, place, person)

• Pt alert but confused to x3
• NVS stable
• Active ROM present, AAT

Respiratory

• Resps easy + reg

• A/E clear to bases
• A/E dec to bases with crackles audible to bases/all lung fields/ lower lobes bilat
• O2 sats satis on R/A, or 3L O2 via NP
• O2 sats 88% on R/A, O2 applied at 2L via NP, pt enc to DB+C q1h
• Wet or dry cough noted, no sputum noted
• Yellow sputum noted upon coughing, sputum sent for C&S, pt enc to DB&C

Cardiovascular

• Apical pulse ____ and regular

• CWMS satis to all extremities
• RPP bilat (radial pulses palpable bilaterally)
• PPP bilat (pedal pulses palpable bilaterally)
• No edema noted to feet/legs/arms
• cap refill satis & <2secs
• No S+S of DVT noted, Homan’s sign (-) or (+), no calf tenderness voiced

GU

• Silastic cath / Foley #16Fr insitu and draining clear amber urine/draining cloudy urine with
sediments, urine sent for C&S
• Foley drained 500cc of clear amber urine
• Foley care given in am or at hs
 • Pt upto BR to void indep/with 1P assist
• Pericare given

GI

• Abd soft/dist/firm, BS x4, flatus present/no flatus present

• Pt tolerating CF/FF/Gen diet, no nausea voiced
• Pt ate 50% of breakfast/lunch
• LBM…….., Supp given,
• Pt had sm/med/lg soft/formed/constipated/loose brown/green colored BM
• Feeding tube insitu, insertion site satis, no S+S of infection noted at insertion site
• Tube feeds running at ____cc/hr, pt tolerating well

Skin

• Skin healthy, no open areas noted, no skin breakdown noted

• Skin warm to touch, color satis
• No redness noted to coccyx
• No breakdown noted to bony prominences
• Braden scale score…….
• Pt turned q2h to avoid skin breakdown

Musculoskeletal

• AAT/ up with 1P assist/ pt up indep with Walker/ W/C

• Pt upto BR to wash indep/1P assist

Psychosocial

• Pt able to verbalize concerns

• Pt understands medication teaching/diabetic/diet/pain control teachings
• Family in to visit and at bedside

Dressings/incisions

• Drsg D+I, incision satis, incision well approx, staples insitu, no S+S of infection noted
• Drsg chg’d for mod amt of sero-sang drainage, incision satis & well approx, sutures insitu,
incision cleansed with NS, mepore + abd pad applied, pt tolerated well
• Staples removed as per orders, incision well approx & satis, S/S applied, pt tolerated well
• Incision open to air & satis, no S+S of infection noted, S/S D+I

Drains

• Snyder/HMV drain insitu & draining sere-sang drainage in small amts, suture insitu at the drain
exit site, no S+S of infection noted, area cleansed with NS, gauge & tape applied