Documentation of Ventilatory Support 215a
Dec 13, 2015
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