Documentation Guidelines

• Respiratory status of the patient: Respiratory rate, breath sounds, use of oxygen, color of nail beds and lips; note any respiratory distress

• Response to activity: Degree of shortness of breath with any exertion, degree of fatigue

• Comfort, body temperature

• Response to medications, oxygen, and breathing treatments

• Need for assistance with activities of daily living

• Response to diet and increased caloric intake, daily weights

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