Source,TTY

 1  HHC96IN|       3]~Actions performed to document condition by nurse.~Nutrition
 2  HHC96IN|       2]~Actions performed to document condition by physician.~
 3  NIC96AC|  U000103]~----~Administer and document preoperative medications,
 4  NIC96AC|     U002134]~----~Develop and document an anesthetic plan appropriate
 5  NIC96AC|      C0510418] [U002357]~----~Document accuracy of count on appropriate
 6  NIC96AC|      C0510419] [U002358]~----~Document action and patient response
 7  NIC96AC|      C0510420] [U002359]~----~Document actions and patient response,
 8  NIC96AC|      C0510421] [U002360]~----~Document all allergies in clinical
 9  NIC96AC|      C0510422] [U002361]~----~Document any disagreement with a
10  NIC96AC|      C0510423] [U002362]~----~Document appearance of umbilical
11  NIC96AC|      C0510424] [U002363]~----~Document appropriate information
12  NIC96AC|      C0510425] [U002364]~----~Document cardiac dysrhythmias [C0510426] [
13  NIC96AC|      C0510426] [U002365]~----~Document care provided, as required [
14  NIC96AC|      C0510427] [U002366]~----~Document cart check, per agency policy [
15  NIC96AC|      C0510428] [U002367]~----~Document changes in fetal heart patterns
16  NIC96AC|      C0510429] [U002368]~----~Document changes in intrapartal electronic
17  NIC96AC|      C0510430] [U002369]~----~Document characteristics of fluid,
18  NIC96AC|      C0510431] [U002370]~----~Document cleaning and maintenance,
19  NIC96AC|      C0510432] [U002371]~----~Document color, amount, and character
20  NIC96AC|      C0510433] [U002372]~----~Document continued need for health
21  NIC96AC|      C0510434] [U002373]~----~Document degree of skin breakdown [
22  NIC96AC|      C0510435] [U002374]~----~Document events of birth [C0510437] [
23  NIC96AC|      C0510437] [U002376]~----~Document events of labor [C0510438] [
24  NIC96AC|      C0510438] [U002377]~----~Document factual information about
25  NIC96AC|      C0510439] [U002378]~----~Document findings [C0510441] [U002380]~----~
26  NIC96AC|      C0510441] [U002380]~----~Document in patient record that physician
27  NIC96AC|      C0510442] [U002381]~----~Document infant response to restraints,
28  NIC96AC|      C0510443] [U002382]~----~Document information about seizure [
29  NIC96AC|      C0510444] [U002383]~----~Document information, as per agency
30  NIC96AC|      C0510445] [U002384]~----~Document instrument calibration,
31  NIC96AC|      C0510446] [U002385]~----~Document medication administration
32  NIC96AC|      C0510448] [U002387]~----~Document medications administered
33  NIC96AC|      C0510449] [U002388]~----~Document mental state, physical state (
34  NIC96AC|      C0510450] [U002389]~----~Document modification process, as
35  NIC96AC|      C0510451] [U002390]~----~Document monitor interpretation,
36  NIC96AC|      C0510452] [U002391]~----~Document nursing assessments and
37  NIC96AC|      C0510453] [U002392]~----~Document nursing assessments, nursing
38  NIC96AC|      C0510454] [U002393]~----~Document patient education, lab results,
39  NIC96AC|      C0510455] [U002394]~----~Document patient progress toward
40  NIC96AC|      C0510456] [U002395]~----~Document patient's discharge plans
41  NIC96AC|      C0510457] [U002396]~----~Document patient's pain, amount and
42  NIC96AC|      C0510458] [U002397]~----~Document pertinent information [C0510459] [
43  NIC96AC|      C0510459] [U002398]~----~Document presence of thick meconium
44  NIC96AC|      C0510460] [U002399]~----~Document procedures (e.g., anesthesia,
45  NIC96AC|      C0510461] [U002400]~----~Document pulmonary artery and systemic
46  NIC96AC|      C0510462] [U002401]~----~Document quality control checks,
47  NIC96AC|      C0510463] [U002402]~----~Document rationale for restrictive
48  NIC96AC|      C0510464] [U002403]~----~Document reason for removal and condition
49  NIC96AC|      C0510465] [U002404]~----~Document reason for variances from
50  NIC96AC|      C0510466] [U002405]~----~Document relevant intrapartal care (
51  NIC96AC|      C0510467] [U002406]~----~Document response to analgesic and
52  NIC96AC|      C0510468] [U002407]~----~Document results of tests, according
53  NIC96AC|      C0510469] [U002408]~----~Document site, needle type and size,
54  NIC96AC|      C0510470] [U002409]~----~Document site, needle type and size,
55  NIC96AC|      C0510471] [U002410]~----~Document skin status on admission
56  NIC96AC|      C0510472] [U002411]~----~Document strengths and weaknesses
57  NIC96AC|      C0510473] [U002412]~----~Document strip interpretation, activities
58  NIC96AC|      C0510474] [U002413]~----~Document that physician was notified
59  NIC96AC|      C0510475] [U002414]~----~Document the content presented, the
60  NIC96AC|      C0510476] [U002415]~----~Document the number of patients who
61  NIC96AC|      C0510477] [U002416]~----~Document the patient's progress on
62  NIC96AC|      C0510478] [U002417]~----~Document the patient's responses
63  NIC96AC|      C0510479] [U002418]~----~Document the rationale for use of
64  NIC96AC|      C0510464] [U002419]~----~Document time frame of transfusion [
65  NIC96AC|      C0510480] [U002420]~----~Document time of initiation of collecting,
66  NIC96AC|      C0510481] [U002421]~----~Document time, sequence, and neonatal
67  NIC96AC|      C0510482] [U002422]~----~Document tourniquet identification
68  NIC96AC|      C0510483] [U002423]~----~Document use of major equipment or
69  NIC96AC|      C0510484] [U002424]~----~Document uterine activity, using
70  NIC96AC|      C0510485] [U002425]~----~Document volume infused [C0510486] [
71  NIC96AC|      C0510486] [U002426]~----~Document wasting of controlled substances [
72  NIC96AC|      C0510487] [U002427]~----~Document whether patient has showered,
73  NIC96AC|    U003054]~----~Evaluate and document level of sedation for patients
74  NIC96AC|    U003055]~----~Evaluate and document response to distraction [
75  NIC96AC|    U003056]~----~Evaluate and document response to guided imagery [
76  NIC96AC|    U003057]~----~Evaluate and document response to heat/cold application [
77  NIC96AC|    U003058]~----~Evaluate and document response to massage [C0511103] [
78  NIC96AC|    U003059]~----~Evaluate and document response to stimulation [
79  NIC96AC|    U003060]~----~Evaluate and document the effectiveness of TENS
80  NIC96AC|    U003061]~----~Evaluate and document the response to relaxation
81  NIC96AC|  markings on the ET tube, and document [C0512881] [U004859]~----~
82  NIC96AC|     U004957]~----~Monitor and document heart rate, rhythm, and
83  NIC96AC|      care/school settings and document as required by state regulations [
84  NIC96AC|     to therapy and report and document, according to agency protocol [
85  NIC96AC|     U006235]~----~Perform and document the patient's health history
86  NIC96SA|      C0510355] [U002294]~----~Document elements of the external
87  NIC96SA|      C0510436] [U002375]~----~Document fetal response to internal
88  NIC96SA|      C0510440] [U002379]~----~Document maternal response to application
89 PCDS97OR|     14000.02]~----~Assess and document substance abuse history. [
90 PCDS97OR|            Assess hemodynamic document hemodynamic effect of discomfort
91 PCDS97OR| C0547143] [ORC_00200.06]~----~Document burn or wound appearance
92 PCDS97OR| C0548306] [ORC_18220.00]~----~Document observed negative behaviors. [
93 PCDS97OR|  Inspect skin of entire body; document significant changes. [C0548254] [
94 PCDS97OR|     sitting and with turning; document significant changes. [C0548255] [
95 PCDS97OR|                   Observe and document difficulty swallowing. [
96 PCDS97OR|    14060.03]~----~Observe and document appearance of skin or muscle
97 PCDS97OR|       family interactions and document. [C0547389] [ORC_04010.02]~----~