Documentations Tips: Dialysis appointments

Hi guys, I’m sure there are a lot of posts like this already. And I’ve read most of them I think... but I still need a lot of help with my charting.

I work in a LTC facility. My patient left for hemodialysis today and I did NOT know what to write. I knew what I had to do & assess but I didn’t know how to put in words what I did.

“Resident left for dialysis appointment @ 1135 via wheelchair. Alert & verbal. VS: ______________. Consumed 100% of lunch. Paperwork & snack in hand. Awaiting for return. “

Any other information I should add next time? Also I found myself so scared that he will come back during my shift.... only because I didn’t know what to document once he comes back.

If if you’re still reading, any tips for COC charting? The ones that aren’t urgent enough to page the doctor without them getting furious.

- Weight loss/gain in one week

72 hour monitoring for things like:

- s/p vaccine

- s/p abx therapy: IM & PO