Drowning: Documentation (Nursing)

00:01 If you're caring for a client who has experienced drowning, there are some very specific things you need to document.

00:08 I want to walk through some examples so you know what to do.

00:11 First, let's start with the initial assessment.

00:13 As much as you can gather about the circumstances of the drowning is really important to get down in the record.

00:19 You can get information from the first responders and from the family document both. So you want the circumstances around the drowning incident.

00:27 What time did it happen? What location were they at? What was the type of water? Was it pool water or lake water or ocean water? How long were they submerged? As best you can, get the information from these providers or the family members and put everything in quotation marks, use their exact wording on how they reported it.

00:48 Now you also, of course, want the initial vital signs and what you find in your assessment.

00:52 You want to know what resuscitation measures were done before the patient came to the hospital, and make sure those are documented in your charting with the initial assessment.

01:02 Now what you did, you want to make sure you record that in the appropriate timed sequence that you did them, and also document how the patient responded to the interventions that you tried. Now, once we've got the initial assessment done, we've got the ongoing documentation.

01:17 Of course, that's going to include vital signs and your neuro assessments, how they're doing respiratory wise.

01:22 What's their status. Are they requiring oxygen? Are they not. If they're on a ventilator.

01:28 You want to make sure you've documented all their ventilator settings in any changes that you've made, and how they responded to those changes.

01:36 Hemodynamic parameters are also critically important to document how stable or unstable the patient is.

01:42 Fluid balance always comes into play.

01:45 Any medications that you give that client and the effects of those medication, is it what you wanted, the desired effect or did it have an undesired effect or adverse effect? You're going to evaluate their laboratory and their diagnostic tests and make sure those are also documented in your chart.

02:01 Now, if the patient has any change in their condition, positive or negative, make sure that it's clearly documented in your chart, using objective language as many measurements as you can to support that. Now, if you have to do a procedure with the patient, maybe they're intubated or they have a central line placement, you want to make sure that is also documented in your chart.

02:24 And there's very specific things for each of these procedures.

02:27 But I just want you to have in mind if they're intubated, if they place a central line, if they put in a chest tube or they have a bronchoscopy, you're going to document that that procedure was done and as many details as are appropriate outside of what might be in the official report. Now, as far as interdisciplinary documentation, any consults or recommendations that are made? You want to make sure there's a note of that in the chart. And what happened when that consultation responded.

02:56 If you have a care conference or a family meeting, make sure you carefully document the main points about those discussions.

03:03 You're going to educate your patients. So document that you educated the patient and or the family. And exactly what did you provide? Demonstration is the best way for your patients to validate to you that they actually understood what you said.

03:18 Remember, anyone in a hospital setting is under stress.

03:21 That's a really difficult time to learn.

03:24 So be patient with them.

03:26 Make sure they can demonstrate understanding of the points that you've made with them, and make sure that's documented in your chart.

03:33 If you give them educational materials, remember that's not education.

03:37 You can't just print off a stack of papers and hand it to somebody and say, Bing, you have been educated.

03:43 Make sure you take the time and ask them questions and have them demonstrate that they understand what you've educated them about.

03:51 Document any follow up appointments that you recommended to the client, and make sure you have those listed on their discharge paperwork.

03:58 Document all the things you do for discharge planning, equipment needs and how you help them receive that information.

04:06 Home care instructions, referrals that were made, everything that you cover and discharge planning needs to be completely documented in the chart.