Charting help

14 hours ago, Beastmom0911 said:

How would you chart a bolus Mickey feed, bath for non mobile, non verbal Pt, diaper changes, therapies. I have been doing this everyday for months and I feel like my charting is so boring cause it’s the same exact words every time. I just need different charting combinations. Neb treatments, pump feedings, neuro checks and seizures. I know this may sound dumb but I need different word combinations. Please help. Thank you. 

Below are some ideas for charting. The trick is to chart more fully on a different topic each day. 

Bolus Mikey feed: Tolerated well? Asleep? Playing with ______.

"Feed tolerance is how well a child tolerates feeds. A child who is comfortable and happy during and after tube feeds is tolerating them well. If a child is uncomfortable, agitated, unhappy, retching, gagging, vomiting, swallowing hard, or experiencing diarrhea or excessive gas may not be tolerating feeds well." https://www.bing.com/search?q=tolerating+tube+feed&form=ANNTH1&refig=464358b197bf466cb5a286025773c8f7&sp=6&qs=HS&sk=PRES1HS5&sc=8-0&cvid=464358b197bf466cb5a286025773c8f7

Bath for non-mobile: Condition of skin. Lotion used? Soak hands or feet in basin of water? (Or soak feet by wrapping feet in warm wet hand towel in a plastic bag - to protect the bedding - and then cleaning off all the old dead skin and trim or file the nails.)  Range of Motion.

Non-verbal: Reaches for toys? Smiles? Frowns? How does he communicate?

Diaper changes: Frequency (more or less than usual)? Color & odor of urine? BM soft? Firm? Peasoup?

Neb treatments: Lung sounds and work of breathing before and after. Does he cooperate easily? If not, how do you deal?

Pump feedings: How tolerated? Does he pull on the tubing and how do you deal with this (distraction? decoy? cover the tubing? Etc..) Condition of stoma? Leaks?

Neuro checks: PERRLA? https://www.healthline.com/health/perrla-eyes#what-it-stands-for

Seizures: Describe seizure, activity before seizure. Frequency typical for this child?

Your charting doesn’t have to be interesting. It just needs to be accurate and to the point.