How to Document ABG Results in the Notes

If you'd like to support us, check out our awesome products:

In addition to knowing how to performΒ 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 findings of an ABG in a patient’s notes.


Documentation basics

Before we discuss how to document the findings of an ABG, 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 notesΒ for more information.

What should I use to write with?

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

Patient details

For every new sheet of paper, your first task should be to document at least three key identifiers for the relevant patient:

  • Full name
  • Date of birth
  • Unique patient identifier
  • Home address

If a patient label containing at least three identifiers is available, then this can be used instead of writing out the information manually.

Location details

You should indicate the patient’s current location on the continuation sheet:

  • Hospital
  • Ward
Patient identifiers
Patient identifiers
You might also be interested in our premium collection of 1,000+ ready-made OSCE Stations, including a range of documentation stations ✨

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.

The next documentation steps include:

1.Β Adding the date and time (in 24-hour format) of your entry.

2.Β Writing your name and role as an underlined heading.

Beginning an entry
Beginning an entry

Documenting the ABGΒ results in the notes

1. Document the time and date that the ABGΒ was performed as this may be significantly different from the time you are documenting.

2. Write the indication for the ABGΒ (e.g. hypoxia).

3. Document the ABG results and yourΒ interpretation of themΒ (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).
  • PaO2: make sure to also document if the patient was on oxygen at the time the ABG was performed (including the flow rate and the oxygen delivery device).
  • pH
  • PaCO2
  • HCO3
  • Base excess

If any of the results are abnormal you should highlight them, either by underlining or circling them. You canΒ 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.

Documenting ABG interpretation & plan
Documenting ABG interpretation

Completing the entry in the notes

At theΒ end of your entryΒ to need toΒ includeΒ theΒ 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)
Completed entry
Completed entry

 

Print Friendly, PDF & Email
Contents