Charting: an exceptionally effortless! Pocket Guide offers time-starved nurses with crucial documentation directions in a streamlined, bulleted structure, with illustrations, emblems, and different Incredibly Easy! gains. The publication is very easily pocket sized for speedy reference each time and anywhere.
The first part experiences the fundamentals of charting, together with forms of files, dos and dont's, and present HIPAA and JCAHO rules. the second one part, alphabetically equipped, offers countless numbers of examples and directions for appropriately charting daily occurrences. trademarks comprise Help Desk most sensible practices guidance; Form Fitting accomplished kinds that exemplify top-notch documentation; Making a Case documentation-related complaints; and Memory Jogger mnemonics.
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Additional info for Charting: An Incredibly Easy! Pocket Guide
Memory jogger When documenting a code, use the mnemonic WE CARE to help remember what to include in your notes: Who initiated cardiopulmonary resuscitation Events leading up to the code Care provided before code team arrived Assessment findings prompting the code Response of patient to interventions Events documented in a code sheet. ’s room at 0630 by a shout from roommate. Found pt. unresponsive in bed without respirations or pulse. Ç Code called at 0630. Initiated CPR with Ann Barrow, RN. Code team arrived at 0632 and continued resuscitative efforts.
With ambulation in the hallway at 1640, pt. c/o feeling weak and dizzy. Pt. Ç Pt. stated he never felt like this before. Apical rate 170; BP 90/50; RR 24; peripheral pulses weak; skin cool, clammy, and diaphoretic. Denies chest pain or SOB. Breath sounds clear bilaterally. Pt. placed in wheelchair and assisted back to bed without incident. O2 via NC started at 2 L/min. Dr. Brown notified at 1645 and orders noted. Lab called to draw stat serum electrolyte and digoxin levels. Stat ECG revealed PSVT at a rate of 180.
In wheelchair to main lobby with wife. Pt. left at 1445. qxp 3/15/12 10:51 AM Page 25 Anaphylaxis 25 Anaphylaxis g k _ N • A severe reaction to an allergen after reexposure to the substance, anaphylaxis is potentially fatal and requires emergency intervention. • If airway, breathing, and circulation become compromised, cardiopulmonary resuscitation may be necessary. • Monitor vital signs frequently. V. line open with a normal saline solution infusion. • Contact the practitioner immediately and anticipate orders, such as administering an epinephrine injection.