SAMPLE CHARTING: New Pay Ward
Time | |
3 pm
4:00 pm 4:30 pm
5:30 pm
6:00 pm 6:10 /10:30 pm
7:00 pm
8:00 pm
11:00 pm
|
Received with an IVF of D5 Water 500 cc + 4 ampules of hydrazaline on around 350cc & regulated at 10 mgtts/min
With oxygen inhalation on via nasal cannula at 2-3 L/min With nasogastric tube intact for feeding With foley catheter to urine bag with yellowish output With on and off productive cough BP = 120/80 mmHg; T= 37.9 OC Tepid sponge bath done for 15 minutes & cold compress placed over the forehead Sent down to radiology department per stretcher for cranial CT scan accompanied by son and undersigned, and came back after 20 minutes Seen by Dr.________ with orders Above IVF dislodged due to swelling and saved set; IV catheter prescribed Placed on semi-fowlers position; Osterized feeding of 160 cc + 50 cc water given per NGT & tolerated well Sensitivity test of Metronidazole done on left forearm and revealed negative as interpreted by Dr. _________ Above IVF reinserted aseptically on right metacarpal vein using IV catheter g.20 and regulated to 10 mgtts/min. No dyspnea noted BP = 130/80 mmHg; T = 37.2 0C Endorsed for continuity of care |
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