Injection goes on the MAR....we just sign in the little box to say it was done & went well
Vitals just get written on the Vitals record sheet. Numbers, no description. Unless theres something to note, then it goes into the Nursing notes with ur assessment findings.
Nov 18, '06
I just did my first acute care placement and we had to do computer charting.Vitals had places for info like what kind of thermometer,what position were they in, which arm etc.For bp it asked what kind of cuff and again what position they were in.For respirations it asks if resps were labored or non-labored. I know for paper charting you just record the numbers.
I'm curious as to how you document what you have done like giving injection or taking vitals? Does any one have any examples? Thanks
Are you refering to the Nurses notes? If so here is what we are being taught.
1800 B/P 136/84 P 78 T 99.3 R 15 o2 96% reports resting comfortably
then we just sign it J.Doe SN/SU---------------------------
I "believe" that the MAR is the only documentation of record for administering meds.
Does this help?
Nov 22, '06
Yes, it does help. Thank you so much!
Nov 22, '06
We were taught to document any PRN meds given in the progress notes as well as response to the med.