Record the date and time of your entry. Chart the date of insertion, type of pacemaker (demand or fixed rate), rate of pacing, chambers paced, chambers sensed, how the pulse generator responds, and whether it’s rate-responsive. If the patient knows the three or four-letter pacemaker code, record it. (See Pacemaker codes, page 272.) Document your patient’s apical pulse rate, noting whether it’s regular or irregular. If the patient is on a cardiac monitor, place a rhythm strip in the chart. Note the presence of pacemaker spikes, P waves, and QRS complexes and their relationship to each other. Ask the patient about and record symptoms of pacemaker malfunction, such as dizziness, fainting, weakness, fatigue, chest pain, and prolonged hiccups. Check the pacemaker insertion site and describe its
condition. Assess and document your patient’s understanding of his pacemaker.

Record the date and time. Chart the patient’s heart rate and rhythm. Note the pacemaker rate and the output, in milliamperes (mA), at which capture occurs. Describe whether or not all QRS complexes are captured: record as percentage (such as 100% capture). Place a rhythm strip showing pacemaker function in the chart, if available. Describe the condition of the skin at the electrode sites and any skin care performed. Record your assessment of the patient, including skin color and temperature, mental status, and urine output. Document measures to reduce anxiety and provide comfort as well as the patient’s response to these measures. Record patient teaching and emotional support given.

Record the date and time of pacemaker care. Chart the pacemaker’s settings. Document the patient’s vital signs and include a rhythm strip in your note. Place a rhythm strip in the chart whenever pacemaker settings are changed or when the patient is treated for a complication caused by the pacemaker. Document interventions to prevent shock and pacemaker malfunction. Chart your assessment of the pacemaker insertion site, noting drainage, redness, and edema. Describe site care and document dressing changes. Include signs and symptoms of other complications, the name of the doctor notified, the time of notification, orders given, your interventions, and the patient’s response. Record patient education and emotional support rendered.

Chart the date and time transcutaneous pacing is initiated. Record the reason for transcutaneous pacing and the location of the electrodes. Chart the pacemaker settings. Note the patient’s response to the procedure along with complications and interventions. If possible, obtain rhythm strips before, during, and after pacemaker use; whenever settings are changed; and when the patient is treated for a complication caused by the pacemaker. Describe the frequency of paced or captured beats. As you monitor the patient, record his response to temporary pacing and note changes in his condition. Record patient teaching, emotional support, and comfort measures provided.

Record the date and time of your entry. Record the time that your patient returned to the unit. Document the type of pacemaker used, pacing rate, and doctor’s name. Verify that the chart contains information on the pacemaker’s serial number and its manufacturer’s name. Note whether the pacemaker reduces or eliminates the arrhythmia and include other pertinent observations, such as the condition of the incision site and the percentage of paced or captured beats. Chart the patient’s vital signs and level of consciousness every 15 minutes for the first hour, every hour for the next 4 hours, every 4 hours for the next 48 hours, and then once every shift, or according to facility policy or doctor’s order. You may record these frequent assessments on a critical care or frequent vital signs flow sheet. Assess for and record signs and symptoms of complications, such as infection, lead displacement, perforated ventricle, cardiac tamponade, or lead fracture and disconnection. Record the name of the doctor notified, the time of notification, interventions, and the patient’s response. Document your patient teaching. This may be recorded on a patientteaching flow sheet.

Record the date and time that the pacemaker was inserted, the reason for pacing, and the location of the insertion site. Chart the pacemaker settings and the frequency of paced or captured beats. Document the patient’s level of consciousness and cardiopulmonary assessment, including vital signs. Note the patient’s response to the procedure, complications, and interventions. Include a rhythm strip in your note. Document your assessment of the insertion site and your neurovascular assessment of the involved limb, if appropriate. Record your patient teaching and the support you gave.

Record the date and time of the malfunction. Record your patient’s signs and symptoms, such as dizziness, syncope, irregular pulse, pale skin, dyspnea, chest pain, hypotension, heart rate below the pacemaker’s set rate, palpitations, hiccups, and chest or abdominal muscle twitching. Place a cardiac rhythm strip in the chart, if possible, noting the percentage of captured beats or malfunctioning of the pacemaker, such as firing without capturing. Note the name of the doctor notified, the time of notification, and the orders given, such as obtaining a stat ECG, placing a magnet over a permanent pacemaker, and preparing for temporary pacing. If a
temporary pacemaker malfunctions, chart your troubleshooting actions, such as repositioning the patient and checking connections and battery settings; the results of these efforts; and the patient’s response. Be sure to include patient education and emotional support provided.

When charting pain levels and characteristics, describe the location of the pain and note if it’s internal, external, localized, or diffuse. Record whether the pain interferes with the patient’s sleep or activities of daily living. In the chart, describe what the pain feels like in the patient’s own words. Chart the patient’s description of how long the pain lasts and how often it occurs. Record the patient’s ranking of his pain using a pain rating scale.

Describe the patient’s body language and behaviors associated with pain, such as wincing, grimacing, or restlessness. Note sympathetic responses commonly associated with mild to moderate pain, such as pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Record parasympathetic responses commonly associated with severe, deep pain, including pallor, decreased blood pressure, bradycardia, nausea and vomiting, dizziness, and loss of consciousness.

Chart situations that worsen the pain as well as interventions that relieve or decrease the pain, including heat, cold, massage, or drugs.

Document interventions taken to alleviate your patient’s pain and the patient’s responses to these interventions. Also, note patient teaching and emotional support provided.

Document that the procedure and its risks have been explained to the patient and that a consent form has been signed. Chart what you taught the patient about the procedure. Your facility may require you to document patient education on a patient-teaching flow sheet. Record baseline vital signs, weight, and abdominal girth. Indicate that the abdominal area measured was marked with a felt-tipped marking pen.

Record the date and time of the procedure. Describe the puncture site and record the amount, color, viscosity, and odor of the aspirated fluid. Also, record the amount of fluid aspirated in the fluid intake and output record. Record the number of specimens sent to the laboratory. Note whether the wound was sutured and the type of dressing that was applied.

Record the patient’s tolerance of the procedure, vital signs, and signs and symptoms of complications (such as shock and perforation of abdominal organs) that occur during the procedure. If peritoneal fluid leakage occurs, document that you notified the doctor, any orders given, your actions, and the patient’s response.

Keep a record of the patient’s vital signs and nursing activities related to drainage and dressing changes. Document drainage checks and the patient’s response to the procedure every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, and then every 4 hours for the next 24 hours (or according to your facility’s policy). Continue to document drainage characteristics, including color, amount, odor, and viscosity. Document daily patient weight and abdominal girth measurements after the procedure.

Record the date and time of your entry. Note the type of lipid solution, its volume, and the infusion rate. Document whether the lipids are being given peripherally or centrally, and note the location of the line. Record vital signs before starting the infusion, at regular intervals during the infusion (according to your facility’s policy), and following the infusion. In the intake and output record, chart the amount of lipids infused. Document site care and describe the condition of the insertion site, cleaning the site, and the type of dressing applied. Also, record tubing and lipid solution changes. Monitor the patient for adverse reactions, and document your observations, interventions, and the patient’s response. Record what you teach the patient about lipids.

Record the date and time of your entry. Document the type and location of the CV line and the volume and rate of the solution infused. Record the amount of TPN infused on the intake and output record. Document site care, describing the condition of the insertion site, cleaning of the site, and the type of dressing applied. Many facilities document all this information on an I.V. flow sheet. (See I.V. flow sheet, page 232.) Monitor a patient receiving TPN for adverse reactions, such as hyperglycemia, hypoglycemia, air embolism, extravasation, phlebitis, pneumothorax, hydrothorax, septicemia, and thrombosis, and document your observations, interventions, and the patient’s response to them. Record what you teach the patient about TPN.

When you discontinue a CV or peripheral I.V. line for TPN, record the date and time and the type of dressing applied. Also, describe the appearance of the infusion site.

Be sure to document the name of the opioid used, lockout interval, maintenance dose, amount the patient receives when he activates the device, and amount of opioid used during your shift. Record the patient’s assessment of pain and pain relief and patient teaching you perform. Document your patient’s vital signs and level of consciousness according to your facility’s policy. Record your observations of the insertion site. See PCA flow sheet, page 286, for an example of documentation.

If your patient asks to see his medical record, use your facility’s form or have the patient draft a written request to see his medical record, according to your facility’s policy. Chart the parts of the medical record that the
patient requested and whether copies were given to the patient. Record the names of the nursing supervisor, manager, and doctor who were notified of the patient’s request. Record the date and time that the patient reviewed his record and the name of the person who stayed with the patient while he read it. Document the patient’s response to reading his record and whether he had questions or concerns.

Record the date and time of your entry. Document the presentation of a search warrant by law enforcement agents. Chart the time of the presentation of a search warrant and the names of the nursing supervisor, hospital
administrator, and doctor who witnessed the presentation. Record the rationale given for searching the patient’s belongings. Document compliance with your facility and local law enforcement policies and procedures before instituting the search. Record the time that the search occurred, the name of the person conducting the search, and the names of others present. Complete an incident report if required by your facility.

Record the date and time that you taught the patient about self-documentation. In your note, describe what you instructed the patient to measure or time or the symptoms to record and how frequently this should be done. Record the patient’s response to this teaching. Describe the type of record keeping he’s using. Document that the patient is able to verbalize understanding or give a return demonstration. Include any written materials given to the patient. Record that the patient knows who to call with questions or for emergency services.

Verify the doctor’s order allowing the patient to use his glucose meter as well as the patient’s ability to use his meter by demonstration. Compare the patient’s first glucose meter reading with the fasting blood glucose level drawn by your facility’s laboratory to correlate the patient’s glucose
meter accuracy. Then, record the date and time that the patient performs self-glucose monitoring. Be sure to document how often the patient tests the quality control of his meter. Also, document the results of the patient’s glucose testing as ordered or per your facility’s policy.

Check your facility’s policies and procedures regarding when, where, and how to document your teaching. Despite their similar content, patientteaching forms vary according to the health care facility. The forms may ask you to document information by filling in blanks, checking boxes, or writing brief narrative notes. Typically, you’ll need to document information about the patient’s learning abilities, barriers to learning, goals to be met, equipment or supplies used, specific content taught, response to
teaching, and skills to be acquired by the time of discharge. You’ll also need to chart how you evaluated the patient’s learning such as by return demonstration or verbalization of understanding Before discharge, document the patient’s remaining learning needs, and note whether you provided him with printed material or other patient-teaching aids.