Accurately document the initial oral labetalol dose and the calculated intravenous equivalent. Record the rationale for conversion, including the patient’s clinical status and the specific indication for intravenous administration. Note any co-morbidities affecting drug metabolism or excretion.
Clearly specify the IV labetalol dose, route of administration (e. g., bolus, infusion), infusion rate (if applicable), and the time of administration. Document the patient’s response to the intravenous medication, including blood pressure readings at regular intervals, along with any adverse effects observed.
Utilize a standardized conversion formula consistently applied within your institution. Reference the specific formula used in the patient’s chart. If deviations from standard protocols occur, thoroughly document the reason for the deviation and the individual responsible for the decision.
After IV administration, document the transition back to oral labetalol (if applicable), including the new oral dosage and the timing. Maintain a consistent record of all vital signs and any adjustments to the dosage regimen.
Remember: Thorough and precise documentation protects both the patient and the healthcare provider. Inconsistent documentation increases the risk of medication errors and potential legal complications. Use clear, concise language avoiding ambiguous terminology.
Example Documentation Entry: “Patient presented with uncontrolled hypertension (BP 200/110 mmHg). Oral labetalol 200mg PO q12h was converted to IV labetalol using the institution’s standard conversion formula (specify formula here). IV labetalol 20 mg bolus administered, followed by 2 mg/min infusion. Blood pressure decreased to 140/80 mmHg within 30 minutes. Patient tolerated the infusion well with no adverse effects reported. Oral labetalol 200 mg PO q12h reinstituted upon stabilization.”
