1. SUBJECTIVE OBJECTIVE DOCUMENTING INFORMATION

2. SUBJECTIVE INFORMATION All information that the patient tells you Document the patient statements in quotations (Pt. states “I don’t feel good.”) Examples = I don’t feel good. I have a headache. I hate this food.

3. OBJECTIVE INFORMATION All information that you see, hear, smell, or touch Who, what, when, where, why Hear Breath sounds Crying Pt. response See ADL’s Skin color Breathing Urine

4. Feel Skin temperature Skin texture Pulse Response to touch Smell Breath odors Poor hygiene Urine/bowel movements Drainage Vomit

5. CHARTING PAIN & MEDICATION 1.Pain – 0 to 10 pain scale; have pt rate their pain 2.Medication – what, dosage, route, pt response to medication 3.Routes – IV – 1 to 2 minutes IM – 5 to 10 minutes PO – 30 to 45 minutes