How do I document taking over a case after acute oxygen desaturation (hypoxemia)?

From the Guidelines

To document taking over a case after acute oxygen desaturation, start by recording the time of care assumption and the patient's current oxygen saturation level, as well as noting the previous healthcare provider's interventions and the patient's response 1.

Key Documentation Points

• Vital signs: Document the patient's current vital signs, including oxygen saturation, heart rate, blood pressure, and respiratory rate.
• Condition changes: Note any changes in the patient's condition, such as increased respiratory distress or altered mental status.
• Oxygen therapy: Record the oxygen therapy being used, including the type (e.g., nasal cannula, face mask, non-rebreather mask) and flow rate (e.g., 2 liters per minute) 1.
• Medications: Document any medications that have been administered, such as bronchodilators (e.g., albuterol 2.5mg via nebulizer) or anxiolytics (e.g., lorazepam 1mg IV).
• ABC assessment: Assess the patient's airway, breathing, and circulation (ABCs) and note any concerns or abnormalities.
• Management plan: Outline the plan for ongoing management, including any changes to oxygen therapy, medications, or other interventions.

Example Documentation

"Assumed care of patient at 14:30 with oxygen saturation of 88% on 4L NC. Previous provider had administered albuterol 2.5mg via nebulizer at 14:00. Patient is experiencing increased respiratory distress with wheezing and cough. Will continue oxygen therapy and administer additional albuterol as needed. Will also consider ordering a stat chest X-ray and arterial blood gas to further evaluate the patient's condition" 1.

It is essential to continuously monitor the patient's oxygen saturation and adjust the oxygen therapy as needed, while also addressing the underlying causes of hypoxemia 1.

From the Research

Documenting Case Takeover after Acute Oxygen Desaturation

To document taking over a case after acute oxygen desaturation (hypoxemia), consider the following steps:

• Review the patient's medical history, including previous episodes of desaturation and any underlying respiratory conditions 2, 3.
• Assess the patient's current oxygen saturation levels and any changes that have occurred since the initial desaturation event 4, 5.
• Evaluate the patient's response to any oxygen therapy that has been administered, including the type and dosage of oxygen 4, 6.
• Consider any potential complications that may have arisen as a result of the desaturation event, such as hypercapnia or respiratory failure 4, 2.

Key Factors to Document

When documenting the takeover of a case after acute oxygen desaturation, be sure to include the following key factors:

• The patient's oxygen saturation levels at the time of takeover, including any changes that have occurred since the initial desaturation event 4, 5.
• The type and dosage of oxygen therapy that has been administered, including any changes to the patient's oxygen prescription 4, 6.
• Any potential complications that have arisen as a result of the desaturation event, such as hypercapnia or respiratory failure 4, 2.
• The patient's medical history, including previous episodes of desaturation and any underlying respiratory conditions 2, 3.

Best Practices for Documentation

To ensure accurate and effective documentation, follow these best practices:

• Use clear and concise language when documenting the patient's condition and any changes that have occurred 4, 5.
• Include all relevant information, including the patient's medical history, oxygen saturation levels, and any potential complications 2, 3.
• Use standardized documentation templates and formats to ensure consistency and ease of use 4, 6.