Thanks a lot! I am confused about how much information to include. Our Prof. don't want to write us stories but the I don't wanna miss on important information as well. If someone can help me in drafting a template which can be used for at least the common skills such as CBI, NGT insertion, Wound dressings, pouchings etc. Thanks again!
I am struggling with documentation. How would I document for the given scenario?
L.M ;56 year old female.
VS- 36.4; 80; 20; 120/85; Sa02 is 90% in RA
MD orders indicate that his Sa02 need to be over 95%.
1. Administer oxygen as ordered.
2. Insert Foley catheter
3. Document care given
Thanks