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what exactly should be documented regarding antibiotic therapy?

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If someone could give me a detailed example I would appreciate it!
Are talking about narrative charting a la LTC?At my facility all most nurses chart is vital signs and "no adverse reactions to ABX". I think that's kind of trite.I say tailor it to whatever they're on ABX for. If it's pneumonia, chart on lung sounds, that the head of the bed is up, if they have a productive cough. If it's a UTI, chart that you're pushing fluids, the color of the urine, if they have urgency. If it's for a wound, chart on the drainage, that you changed a dressing, etc.The fact that you administered the ABX is already in the MAR.

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Depends why they're on antibiotics and what antibiotics/what route, etc. Someone who takes chronic antibiotics for something like acne doesn't need much special documented there. Someone with a massive infection on triples including things like vanco and/or gent that need levels monitored need labs monitored/documented, etc. Someone with a skin infection/abscess should have wound measurements/descriptions documented. The OP is too broad to properly answer it.
Author: jone  3-06-2015, 18:27   Views: 479   
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