11/13/24, 7\:41 PM Guide | Documenting an ABG

Documenting an ABG

Table of contents

Introduction

In addition to knowing how to perform and interpret an arterial blood gas (ABG), it's also important to understand how to
appropriately document the results of an ABG in a patient's notes. This guide provides a structured approach to documenting
the

Documentation basics

Before we discuss how to document the
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
https\://app.geekymedics.com/osce-guides/documentation/documenting-an-abg/ 1/411/13/24, 7\:41 PM Guide | Documenting an ABG
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.
Starting your entry in the notes
https\://app.geekymedics.com/osce-guides/documentation/documenting-an-abg/ 2/411/13/24, 7\:41 PM Guide | Documenting an ABG

Documenting the ABG results

1. Document the time and date that the ABG was performed as this may be signi
documenting.
2. Write the indication for the ABG (e.g. hypoxia).
3. Document the ABG results and your interpretation of them (see our guide to ABG interpretation)\:
A summary of the patient's clinical condition when the ABG was performed (to provide some context for the results).
PaO \: make sure to also document if the patient was on oxygen at the time the ABG was performed (including the
2
and the oxygen delivery device).
pH
PaCO
2
HCO -
3
Base excess
If any of the results are abnormal you should highlight them, either by underlining or circling them. You can also indicate with an
arrow whether the result is abnormally high or low.
4. Document your overall impression of the ABG (e.g.
" m e t a b o l i c a c i d o s i s w i t h r e s p i r a t o r y c o m p e n s a t i o n" ).
5. Document your plan based on the ABG
Documenting ABG results

Completing the entry

At the end of your entry to need to include the following\:
Your full name
Your grade/role (e.g. F2/Medical Registrar)
Your signature
Your professional registration number (e.g. GMC number)
Your contact number (e.g. phone/bleep)
https\://app.geekymedics.com/osce-guides/documentation/documenting-an-abg/ 3/411/13/24, 7\:41 PM Guide | Documenting an ABG
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/documentation/documenting-an-abg/ 4/4