Monday, March 22, 2010

Documentation Tips

If you do your grid from your cardex and perform your interventions make notes that you can understand . When you are out of the patient room. start at the first system and document every thing you did, do not leave out anything, think of the mneumonic for the area of care and write what you did to met that requirement. For example it you have a Enternal Feeding - RAT FEVER is the Mneumonic




F-owler position

E-xamine gastic tube/abdomen

V-erify placement verify G tube placement by aspiration contents of instillin 20 cc of air bolus and listening

E-xpiration date of formulat

R-ecord rate in first 20minutes - a patient that has fluid running must be part of your 20 minute check,

Hope you find this helpful.

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