I am a student & not sure how to chart. It seems if I include something my instructor says I should not have & if I didn't......then of course I should have!
This is an ex. of what I charted & it was wrong any advice appreciated.
0730-Assumed care. Assessment complete. Resting in bed, semi-fowlers position w/eyes open. A&Ox3, b/p 86/50, p 92, t99.0, r16 even nonlabored. No jvd. Wheeze to url on inspiration, Lungs clear LL bilaterally.Chest equal. Abdomen flat, non tender. Bowel sounds ax4q. Denies dyspnea,sob, pain, or needs at this time.Bed low position, rails up x2, call light in reach.............CB