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Document patients' histories, including identifying data, chief complaints, illnesses, previous medical or family histories, or psychosocial characteristics.
||Licensed Practical and Licensed Vocational Nurses
- Observe patients, charting and reporting changes in patients' conditions, such as adverse reactions to medication or treatment, and taking any necessary action.
- Measure and record patients' vital signs, such as height, weight, temperature, blood pressure, pulse, or respiration.
- Administer prescribed medications or start intravenous fluids, noting times and amounts on patients' charts.
- Record food and fluid intake and output.
- Perform and document an initial exam, evaluating data to identify problems and determine a diagnosis prior to intervention.
- Record prognosis, treatment, response, and progress in patient's chart or enter information into computer.
- Test and measure patient's strength, motor development and function, sensory perception, functional capacity, or respiratory or circulatory efficiency and record data.
- Identify and document goals, anticipated progress, and plans for reevaluation.
||Diagnostic Medical Sonographers
- Obtain and record accurate patient history, including prior test results or information from physical examinations.
- Maintain records that include patient information, sonographs and interpretations, files of correspondence, publications and regulations, or quality assurance records, such as pathology, biopsy, or post-operative reports.
- Record patients' medical information and vital signs.
- Monitor, record, and report symptoms or changes in patients' conditions.
- Obtain and record patients' medical histories.
- Maintain accurate case histories of patients.
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