How to Answer Document Nurses Note Questions (Complete Guide)

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Original Question

how to document a nurses note on Twelve-lead ECGs in the ED showed no ST elevation. Location: Progressive Care Unit Time: 15:00 Situation: Carl Shapiro is a 54-year-old male who presented to the Emergency Department a couple of hours ago with complaints of chest pain, diaphoresis, and shortness of breath. He was admitted to the Progressive Care Unit with the diagnosis of non-ST elevation acute coronary syndrome for close monitoring. Background: He has a history of hypertension and states he takes a “water pill” for his blood pressure. He is traveling for work and does not reside locally and came to the ED by ambulance when the symptoms began. No family is present. He was treated with oxygen 2 L per nasal cannula, aspirin, two doses of sublingual nitroglycerin, and a normal saline bolus required after the second dose of nitroglycerin with no recurrent chest pain. Twelve-lead ECGs in the ED showed no ST elevation. Antiplatelet and anticoagulation meds were started and documented in the MAR. Assessment: Mr. Shapiro is alert and oriented times 4. Last set of vital signs was as follows: temperature 98.2 °F (36.8 °C); heart rate 106, sinus tachycardia with a rare PVC; respiratory rate 16; blood pressure 118/78; SpO2 93% on 2 L per nasal cannula; and lung sounds clear. Pain level was rated 0 out of 10. Labs drawn in the ED are in the chart: BMP, CBC, PTT, INR, and BNP are within normal limits. I have not seen the troponin I results. Recommendation: Vi

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