11/13/24, 7\:41 PM Guide | Documenting a CXR

Documenting a CXR

Table of contents

Introduction

In addition to knowing how to interpret a chest X-ray (CXR), it’s also important to understand how to appropriately document
the
notes.

Documentation basics

Before we discuss how to document a CXR, we need to cover the basics that apply to all documentation in a patient’s notes.
You can check out our detailed guide to writing in the notes for more information.

What should I use to write with?

You need to use a pen with black ink, as this is the most legible if notes are photocopied.

Patient details

For every new sheet of paper your
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
manually.

Location details

You should indicate the patient’s current location on the continuation sheet\:
Hospital
Ward
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Patient identi

Beginning your entry

At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at
least three key patient identi
The next documentation steps include\:
1. Adding the date and time (in 24-hour format) of your entry.
2. Writing your name and role as an underlined heading.
3. Adding your entry in the notes below this heading (see the next section for details).
Starting your entry in the notes
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Documenting the CXR results

1. Document the time and date that the CXR was performed as this may be signi
documenting.
2. Write the indication for the CXR (e.g.
p n e u m o n i a" )
" p r o d u c t i v e c o u g h , s h o r t n e s s o f b r e a t h a n d f e v e r - p o s s i b l e c o m m u n i t y-a c q u i r e d
3. Document your interpretation of the CXR\:
Image quality\:
Rotation
Inspiration
Projection
Airway\:
Trachea
Carina and bronchi
Hilar structures
Breathing\:
Lung
Pleura
Cardiac\:
Heart size
Heart borders
Diaphragm\:
Position/shape
Costophrenic angles
Everything else\:
Mediastinal contours
Bones
Tubes/valves/devices
4. Document your overall impression of the CXR (e.g. " l e f t l o w e r l o b e c o n s o l i d a t i o n" ).
5. Document your plan based on the CXR
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Completing the entry

At the end of your entry to need to include the following\:
Your full name
Source\: geekymedics.com
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