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Before you submit

Documentation Checklist

Pick the type of call, check off the required charting points, then submit. The goal is to make the competency obvious to an auditor.

If it is not documented, it may not count. Your chart needs to prove the assessment or skill was indicated, done correctly, and reassessed when needed.

Respiratory call

Respiratory Documentation

Use this for SOB, cough, asthma/COPD, pneumonia, pulmonary edema, or any respiratory complaint.

Always chart: primary assessment vitals pertinent positives pertinent negatives reassessments

Required Checklist

Competencies This May Support

Narrative Prompt

Sample Documentation

Use this as a structure example only. Change the details to match your actual patient, findings, treatments, times, and reassessments.