Sample Documentation

Patient reports post-surgical pain at a level of 8/10. Patient is grimacing when moving in the bed and describes pain as a dull constant ache located in the right lower abdomen surgical incision area that is aggravated by moving or repositioning. Blood pressure 146/80, heart rate 94 bpm, respirations 22 per minute, temperature (tympanic) 98.8°F, pulse oximetry 98%. Last pain medication Ketorolac 30 mg (IM) given 8 hours ago. Incision site is dry and intact. Ketorolac 30mg IM administered per health provider’s prescription in the left ventrogluteal area with 22-gauge needle, length 1 ½ inches. Patient tolerated the procedure without difficulty or increased pain. Injection site post-procedure without bleeding or hematoma.