Mitch T

Here are a couple of examples. And, if I witnesses a consent, I would have included that in the second one as well. I also developed a charting page with pull down menus at http://assessment.homestead.com Example: 2/5/2007 P: The patient has not urinated in 6 hours since arriving at 1345 hospital. IVFs at 125 mL/hr. Patient unable to get up due to doctor's order for bedrest. Patient NPO as ordered since hospitalization. Patient reportedly received 4mg of Morphine IV in ED for pain. I: Assisted patient with bedpan. Water turned on at faucet. E: Patient still unable to void. I: Notified Dr. John Doe of patient's inability to void for last 6 hours since arrival. Foley #20Fr indwelling catheter placed to dependent drainage using sterile technique as ordered. E: 620 mL return of clear yellow urine in bag. Will continue to monitor urine output. Mitchell Taylor, RN PIE charting example: 03/23/09 1500 P: Ineffective Breathing Pattern since admission R/T right pleural effusion stated in the chart. Pt. has diminished lung sounds in the base on the right side and has fine crackles heard throughout the right lobe. O2 sats on 2L/NC 89-90% I: Pleurocentesis ordered by Dr. _______. Placed on 3 L/Nasal cannula as ordered. Increased HOB to 30o. Repositioned patient in bed every 1 hour. Monitored O2 sats to keep them > 90%. Encouraged coughing and deep breathing and assisted with splinting when coughing to minimize pain. Ceftriaxone administered IV as ordered. Assisted with Pleurocentesis procedure with Dr._______ at 1110. Returned 820 mL of brown, thin, liquid sent to lab as ordered. A JP drain was placed by Dr. ______ and connected to bulb suction. E: JP bulb drain output 65 mL of seroganguanous fluid the next hour. Right lung sounds improved, still hear some fine crackles throughout the right lobe, but improved sounds heard in the base of the right lung. Left lung remains clear. Sats improved to 98% on 3L/NC, able to decrease back to 2 L/NC. Will continue to monitor resp. status and esp. right lobe lung sounds.