Charting Help Needed...

Specialties Urology

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I am new to dialysis what should i be mentioning in my notes other just writing stable all the time seems like something is missing help.

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Specializes in Nephrology, Cardiology, ER, ICU.

I moved this to its own thread for more input.

As to what to chart:

1. VS

2. How pt is feeling.

3. Blood flow rate.

4. Meds given.

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Specializes in jack of all trades.

I usually chart what they may be doing at the time:

appears to be resting with eyes closed.

watching tv with no apparent s/s or complaints of discomfort

reading book. Tolerating tx at this time w/o voiced complaints

Snacking w/o complaints of nause. No s/s of hypotensive episode.

Just chart exactly what you see and what you assess at that time. You can never "under" chart. Called Cya. Also chart any follow up to anything the PCT's have done such as saline, etc. Was it effective etc.

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