Sample Documentation

Sample Documentation of Expected Findings

Patient has history of COPD and reported feeling short of breath after getting up to use the bathroom this morning. Respirations 24/minute, pulse oximetry 88% room air. Lung sounds diminished throughout lung fields. Oxygen applied via nasal cannula at 2 lpm and patient encouraged to take slow deep breaths in through their nose and out of their mouth. After five minutes, pulse oximetry 94% 2 liters nasal cannula, respirations 16/minute with patient reporting shortness of breath resolved.

Sample Documentation of Unexpected Findings

Patient has history of COPD and heart failure. Reported feeling short of breath after getting up to use the bathroom this morning. Respirations 30/minute, pulse oximetry 88% room air. Crackles to auscultation in lower posterior lobes. Oxygen applied via nasal cannula at 2 lpm and patient encourage to cough and deep breath. After five minutes, no improvement in respiratory rate or SpO2. Dr. Smith notified at 0715. Order for STAT chest X-ray received and furosemide 40 mg IV STAT. Furosemide administered. 30 minutes later, SpO2 92% with O2 at 2 liters per nasal cannula. Respiratory rate 18/minute. Urine output of 500 mL with decreased crackles in the lower posterior lobes. Patient reported feeling less short of breath.