Complete time of entry at top of column. Complete vital signs as indicated. Record pulse oximetry and Fi02 at the time of the vital signs. Staff person doing care initials column. Ongoing assessments document per legend.
Complete section utilizing breath sounds legend.
Print name and rate of each intravenous fluid or blood product. For continuous infusing IV fluids, list the pump count in the first half of the column. In the second half of the column, list amount of fluid infused since last entry. For fluids infusing over less than 4 hours, amount infused every hour may be recorded. Record volume of all flushes and medicines.