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Observe, record, and report to physician the patient's condition or injury, the treatment provided, and reactions to drugs or treatment.
- Perform and document an initial exam, evaluating data to identify problems and determine a diagnosis prior to intervention.
- Evaluate effects of treatment at various stages and adjust treatments to achieve maximum benefit.
- Identify and document goals, anticipated progress, and plans for reevaluation.
- 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.
||Licensed Practical and Licensed Vocational Nurses
- Administer prescribed medications or start intravenous fluids, noting times and amounts on patients' charts.
- 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.
- Record food and fluid intake and output.
||Critical Care Nurses
- Assess patients' pain levels or sedation requirements.
- Monitor patients' fluid intake and output to detect emerging problems such as fluid and electrolyte imbalances.
- Document patients' medical histories and assessment findings.
- Document patients' treatment plans, interventions, outcomes, or plan revisions.
- Record patients' medical information and vital signs.
- Monitor, record, and report symptoms or changes in patients' conditions.
- Inform physician of patient's condition during anesthesia.
- Document evaluations, treatment plans, case summaries, or progress or other reports related to individual clients or client groups.
- Observe and document client reactions, progress, or other outcomes related to music therapy.
- Collaborate with others to design or implement interdisciplinary treatment programs.
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