| Services Types of beds
Other resources
Labs Imaging Recording in the stab room
Sign outs Asthma Chest Pain Overdose Renal
Patients Seizures
Vaginal Bleed
Wound Care |
- The senior residents rely on your documentation to
dictate and write their chart. This blue paper is not an official document
but be thorough. Vital signs should be recorded every 2-5 minutes or as
often as possible. Document all procedures, medications given, IV lines
placed, physical exam findings, and any history available.
- Ask what is being done if the nurses or residents are not
telling you. They should be talking to you, but you also need to talk to
the people caring for the patient. Give the first vital signs out loud and
any changes or trends in the vital signs need to be communicated.
- Labs – when you are handed the lab sheet tell the
senior the results.
- Intubation – the time from the blade in until the blade
out needs to be recorded in seconds. Once the paralytic is given by the
nurses count out the time in 10 second intervals.
- Recording the case allows you to see what goes on for the
whole case, be as involved as possible and communicate with the physicians
and nurses.
- An example of proper stab room recording is provided on
this page:Stab
Room Recording
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