For those of you who work in an office setting and do blood draws, what do you chart regarding the blood draw? The office I am now working in charts nothing. The MA's and RN's who do blood draws do not chart anything about from where and how the blood is drawn and nothing about the outcome. I'm thinking this is not good!
I think the following should be charted (at least): Pt was seated, procedure explained to pt, venipuncture performed in right a.c. space using aseptic technique, 3 tubes collected, gauze placed with pressure on venipuncture site until hemostasis observed, site clean and dry, no redness or swelling observed, bandage placed, pt voiced no concerns.
If you have any other ideas or ways to shorten the above, please share. Or, if it is common practice NOT to chart about venipuncture in an office setting, please let me know that, too. Thanks!