2 Just wanted some input from all of ya’ll as to how you chart. Also would be interested in seeing examples. This is a sample of how I chart. Any pointers are welcomed.
Pt is an 83 y/o female with ES Cardiac Disease, HTN, AAA and Senile Delirium living in LTCF. At time of this visit pt is found lying in her bed resting. She is awake and alert and oriented x 2. Some confusion and forgetfulness are noted. There are no s/sx of anxiety or depression. She continues to take Citalopram 10mg QD and Ativan 0.5 mg BID. Pain is controlled with Oxy SR 15mg q 12 hours. She has Oxy IR 10 mg and Ultram 50 mg available for BTP. She takes BTP meds 2-3 times per day for pain in her R hand and groin, as well as pain in her abdomen radiating through her chest and shoulder. Pain is a 2 at this time, and this is tolerable to pt. Pt is bed to w/c bound. She is unable to use her walker d/t the cast on her R hand. She is able to self transfer and self propel her w/c with her feet. She continues to have weakness, fatigue, and decreased endurance. She naps frequently throughout the day. She needs assistance with ADL’s and has a HHA 5 x’s q week.
VS – T 98.9, P 84, R 16, BP 133/86, SPO2 97% RA. O2 is available at 2-3 lpm via n/c.
Heart slightly irregular. Cardiac status managed with Lisinopril 5 mg QHS and PRN Clonidine (not recently used). LCTA, diminished. Mild dyspnea/SOB noted at rest, increases with minimal exertion. Abdomen is soft and nontender with BS x 4 quads. LBM yesterday. Pt is occasionally incontinent of B B. Has difficulty getting to her BSC at times d/t her hand being in a cast, and also has difficulty handling the mechanics of toileting. Appetite as well as hydration remain adequate. Current wt 145 lbs. Skin is w/d/i with loose turgor and ashened color. Cap refills 3 sec per finger check. PPP, +1 edema noted to BLE. Karnofsky and PPS at 40, NYHA IV, FAST 6C. POC reviewed. Understanding and satisfaction of care voiced. POC to continue.