Final answer:
For the objective portion of charting, items to document include patient vitals, physical exam findings, lab test results, measurements of bodily functions, and any observable and measurable data.
Step-by-step explanation:
When documenting for the objective portion of charting, several items can be recorded.
It is beneficial to use charts, graphs, and other data visualization tools to clearly represent patient information and outcomes.
These include observable and measurable data such as patient vitals (e.g., heart rate, blood pressure, temperature), physical exam findings, results of laboratory tests, and other diagnostic information.
It is crucial to record any objective evidence that can help healthcare professionals make informed decisions about patient care.
Measurements of bodily functions, like respiratory rate and oxygen saturation levels, are also important to document. Additionally, descriptions of a wound's appearance, the range of motion in joints, and the condition of the skin would be specifics to include.
Exercise 0.5 from LibreTexts suggests the collection of data items such as resting heart rate, which can be included in charting.
In the era of evidence-based medicine, it is essential to complement charting with visuals and media that convincingly demonstrate patient care outcomes.
Charts, graphs, and other data visualization tools can enhance the clarity of the reported information. Particularly when documenting changes over time, visuals can help in quickly assessing patient progress or decline.