Documentation Guidelines

• Episodes of angina describing character, location, and severity of pain; precipitating or mitigating factors; interventions; and evaluation

• Patient teaching about disease process and planned treatments, including medication regimen

• Perioperative hemodynamic response: Pulmonary and systemic arterial pressures, presence of pulses, capillary refill, urine output

• Pulmonary assessment: Breath sounds, ventilator settings, response to mechanical ventilation, secretions

• Complications: Bleeding, blood gas alterations, fluid volume deficit, hypotension, dysrhyth-mias, hypothermia

• Coping: Patient and family

• Mediastinal drainage and autotransfusion

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