How do you document a vital signs field if that particular one was not taken?

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First quarter student here who just had their first clinicals day.
We have an assignment to take complete vitals on a patient, then compile their previous vital signs to compare them, and there are days that both pain assessment and respiration were skipped.
I am required to include SpO2 but the clinic does not take that reading for this patient.

I was just going with "not charted" but I thought I'd check here. We've been given almost do direction and I'm not finding any information in my books about this particular subject.

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Specializes in Mental Health.

16

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Specializes in Stepdown . Telemetry.

What’s the issue? Say No data available.

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Thank you kaylee. And this is why I ask - it's week 4, none of our instructors have covered it (or much about documentation at all or how to word things) and our clinic instructor refused to let us use vitals at all for a patient with Raynaud's who didn't register on the pulse oximeter and gave us a lecture about how everything has to be "complete" and noting in the chart why SpO2 was not included was not adequate.

I imagine I'm already going to get hassled about it even though I have no control over what vitals were done previously, so wanted to ask here for best wording because we were never given options to use. Sounds like you say "no data available" is preferable to saying it was "not charted" for a given set of vitals, so posting here has been useful ?

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Specializes in Stepdown . Telemetry.

Your teacher sounds like a pain in the a$&! I just reworded it because “not charted” could suggest that it was done but not documented, or that the record is incomplete. So instead of using a verb implying an action was or wasnt done, just describe the field as without information.

That’s probably a good rule to follow for charting in general.

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On 10/16/2019 at 5:10 PM, kaylee. said:

Your teacher sounds like a pain in the a$&! I just reworded it because “not charted” could suggest that it was done but not documented, or that the record is incomplete. So instead of using a verb implying an action was or wasnt done, just describe the field as without information.

That’s probably a good rule to follow for charting in general.

Oh thank you! That is a great explanation.

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