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I start by looking for my patient’s chart, I verify my patients dob
I’m going to document the size and type of nasal tube that I used for this procedure.
Also, the technique that I used to assess the tube placement, which was a clean technique.
I’m going to document the consistency of the gastric content, the amount that was drained
And that it was returned into the stomach. The ph of the gastric content was 3, which is acidic
I’m going to document about the nasal and oral hygiene; Nasal cavity was intact, no septic deviation
Oral hygiene was good, no foul odor noted. Gag reflex was ok. No vomiting.
The lungs sounds were normal, no adventitious sounds heard and, normal bowel sounds were heard.
Also, I’m going to document that my patient was able to understand and followed instructions.
And that my patient was able to tolerate this procedure well and with no complications.
And finally, I’m going to sign my note.
Thank you
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