Documentation Guidelines

• Respiratory status: Rate, quality, depth, ease, breath sounds, arterial hemoglobin saturation with oxygen

• Ability to chew, swallow, and speak (swallowing can be subjectively rated by the patient in anticipating ability to swallow food [0 = unable to swallow liquids to 5 = able to swallow regular diet]), food intake, daily weights

• Muscle weakness and strength, speed and degree of fatigue, ability to perform activities of daily living, response to rest, and plans for modification of activity

• Ptosis (can be rated by the nurse [0 = unable to open lid to 5 = uppermost edge of iris visible])

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