Documentation of Ventilatory Support 215a. Educational Objectives List the factors which affect communication Distinguish between subjective and objective.

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Presentation transcript:

Documentation of Ventilatory Support 215a

Educational Objectives List the factors which affect communication Distinguish between subjective and objective data State the importance of accurately recording data in the medical record

Basic Rule of Documentation If it is not documented, it did not happen!

Effective Communication Factors affecting communication in general –Sender –Receiver

Effective Communication Factors affecting communication in the Intensive Care Unit –Stress –Noise –Activity –Number of senders –Complexity of communications

What Needs to be Documented Subjective data –Information obtained from the patient –Information obtained from the patient’s family or significant others

What Needs to be Documented Objective Data –Therapist’s observations of the patient –Ventilator settings

What Needs to be Documented Objective Data –Physical examination of the patient Vital signs Auscultation Sputum production Breathing pattern

What Needs to be Documented Objective Data –Blood gas results –Clinical lab results –Radiology results –Diagnostic test results

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