Forms Book MDS Coordinator's Handbook LTCS Books www.LTCSBooks.com
Skilled Charting Guidelines
Date__________________________ Resident________________________
This resident has been assigned to skilled charting related to: Cardiac Care
|
Hypertension |
|
|
Congestive heart failure |
|
|
Arrythmia |
|
|
New pacemaker |
|
|
Recent heart surgery |
|
|
Hypotension |
Address the following care topics in nurses notes:
Vital signs
Cardiac assessment
Lung sounds
Intake and output
Activity tolerance
Monitoring for jugular vein distention, fatigue, rales, dyspnea, dizziness, clammy skin, edema, chest pain, shortness of breath
Medications and side effects
Oxygen and respiratory treatments
Labs
Effect of illness on ADLs
Copyright © 2009 LTCS Books, Inc.
Call LTCS Books for all of your documentation needs 1-877-881-2404