feelsafewithanurse 10 Posts Specializes in LTC, Geriatrics, MDS. Has 6 years experience. Apr 30, 2013 In my state is once a day with like rehab therapy like PT/OT/ST, q-shift with IV or general nursing. Ill just give an example of what we expect in our notes.Resident cont skilled for PT/OT. A&Ox3. Speech clear and appropriate. Able to voice demands and follow directions. Mucous Membranes moist/pink/intact. Lung sounds clear t/o all fields with no c/o cough or SOB. Resp even and non-labored. Heart rate regular. Abd soft non-tender non-distended with bowel sounds positive x4 quads. Denies n/v or loose stools. Continent of bowel and bladder. Pedal pulses palpable. No edema observed bil. Able to feed self with tray set up. Min assist with ADLs and transfers. Denies c/o pain or discomfort. Will continue to monitor. Also if its for a IV you would chart what they are getting (ABT=reaction? effect?) and the IV site. Just double check with your facility's policy.