11.5: Sample Documentation

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Page ID: 44606

Ernstmeyer & Christman (Eds.)
Chippewa Valley Technical College via OpenRN

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Sample Documentation of Expected Findings

Patient has a history of COPD and reported feeling short of breath after getting up to use the bathroom this morning. Respirations were 24/minute, pulse oximetry 88% on room air, and lungs sounds were diminished. Oxygen applied via nasal cannula at 2 Lpm, and the patient was encouraged to take slow deep breaths in through their nose and out of their mouth. After five minutes, the pulse oximetry was 94%, the respiratory rate decreased to 16/minute, and the patient reported the feeling of shortness of breath had subsided.

Sample Documentation of Unexpected Findings

Patient has a history of COPD and heart failure and reported feeling short of breath after getting up to use the bathroom this morning. Respirations were 30/minute, pulse oximetry was 88% on room air, and lungs had crackles in the lower posterior lobes. Oxygen was applied via nasal cannula at 2 Lpm and the patient was encouraged to cough and deep breathe. After five minutes, the respiratory rate and pulse oximetry readings did not improve. Dr. Smith was notified at 0715 and an order for a STAT chest X-ray was received, followed by an order for furosemide 40 mg IV STAT. Furosemide was administered, and 30 minutes later the pulse oximetry increased to 92%, respiratory rate decreased to 18/minute, and there was urine output of 500 mL with reduced crackles in the lower posterior lobes. Patient reported feeling less short of breath.