COVID-19 SAMPLE DOCUMENTATION GUIDELINES

*Chart in narrative notes if not found elsewhere in the medical record

Daily Assessment/Documentation
Vital signs: Oxygen requirements:
 Temperature  Continuous or intermittent
 Pulse  Liters/minute
 Respirations  Delivery device used
 Blood pressure  Tolerance to weaning
 O2 saturation Precautions:
Order changes  Isolation status
 Respiratory  PPE use
 Antibiotic  Type of precautions taken
 Other Signs of DVT:
Assessment of lungs:  Discoloration, warmth, swelling in legs
Auscultation:  Pain or tenderness to legs, ankles, feet or arms
 Presence and location of rales/wheezes or rhonchi  Swollen, hard, red, tender veins
Breathing patterns:  Sharp chest pain
 Ability to deep breathe  Lightheadedness
 SOB  Rapid breathing
 Unequal chest expansion Medication side effects:
 Sternal/intercostal retractions  Specific medications ____________________________
Suctioning:  Side effect monitoring __________________________
 Frequency Nutritional/hydration status:
 Tolerance  Anorexia
 Secretions  GI distress
Signs of Infection:  Reported loss of taste or smell
 Distention of neck veins Changes in ADL function:
 Sore throat  Improvement or decline in abilities
 Chills  Fatigue
 Shaking/shivering  Endurance
Pain:  Therapy tolerance
 Muscle aches
Psychosocial changes:
 Headache
 Mood
Cough:
 Behaviors
 Frequency
 Personal interactions
 Characteristics of cough
 Sputum: color, consistency, amount Teaching/training needs _______________________________

Response to antibiotic/respiratory therapy:

 Nebulizer treatments
 Metered dose inhaler
 IV medications
 IV site assessment