DIFFICULTY OF BREATHING

>Admitted a (AGE, GENDER) patient under the service of (AP)

>Consent for admission signed and secured.

F> DOB

D> “VERBALIZATION” as verbalized by the (Whom)

 Evidence such as gasping, cyanosis etc…

 Changes in V/S *inc RR, PR, BP, O2 Sat

A> Seen and Examine by ROD (DR.) c orders made and carried out.

 Placed in high-fowlers position/ semi fowlers position.

 Hooked to IVF
 Hooked to O2 inhailation @(1-2) Lmp
 Stat Meds given
 Xray/Labs done
 (Diet) instructed

R> V/S , RR (latest)

 Transferred to Room of choice

 Endorsed properly.