Charting

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Hi all, I am a new student nurse currently struggling with charting. I really appreciate if you could point me in the correct direction on charting this scenario. I walk in the patient room to administer medication and noticed she is out of breath, how do I chat this.

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Specializes in Emergency Department.

What are you using for charting? A paper chart or some kind of electronic health record system? As far as what you're going to chart, you chart what your assessment revealed, who you notified about it, and what was done about the problem. As to what kind of assessment, you're probably going to do a focused assessment.

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Specializes in Pedi.

Under respiratory assessment, I would note "dyspnea" and then make a comment stating that you notified whomever and what was done as an intervention.

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is this a homework question? What do YOU think you'd chart?

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Moved to Nursing Student Assistance forum.

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