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