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 the patient’s notes. This guide provides a structured approach to documenting ABG in a patient’s notes, with included examples.
Before we discuss how to document the ABG itself, 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 here 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).
For every new sheet of paper your first task should always be documenting at least three key identifiers for a patient:
- Full name
- Date of birth
- Unique patient identifier
- Patient’s home address
If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.
You should indicate the patient’s location on the continuation sheet:
Beginning your entry in the notes
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 identifiers at the top.
1. Add the date and time (in 24hr format) of your entry
2. Write your name and role as an underlined heading
3. Make your entry in the notes below this heading (see the next section for details)
Documenting the ABG results in the notes
1. Document the time and date that the ABG was performed (as this may be significantly different than the time you are 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 interpreting an ABG here):
- Summary of the patient’s clinical condition when the ABG was performed (to provide some context for the results)
- PaO2 – ensure to also document if the patient was on oxygen at time of the ABG (including flow rate / percentage / delivery device)
- Base excess
If any of the results are abnormal you should highlight them, either by underlining them 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. metabolic acidosis with respiratory compensation)
5. Document your plan based on the ABG findings
Completing the entry in the notes
At the end of your entry to need to include the following:
- Your full name
- Your grade/role (e.g. Medical student/F2/Respiratory registrar)
- Your signature
- Your professional registration number (e.g. GMC number)
- Your contact number (e.g. phone/bleep)