ICU documentation templates??

  1. 1
    My hospital recently went from paper flow sheets to online. I was wondering if anyone had and templates for organizing their hourly documentation?

    Hourly we have to input vs, intake output, iv fluids, etc

    Any documentation templates would be appreciated!
    Last edit by Joe V on Jul 6, '12 : Reason: spacing
    Joe V likes this.
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  3. 5 Comments so far...

  4. 0
    Define recently? Because you were asking about this exact thing last year when you were a new grad working in a place that had online documentation:

    http://allnurses.com/general-nursing...es-593213.html
  5. 0
    I did ask the same question. Shortly after I started working last year we went "back" to paper flow sheets while the hospital designed their own vfs. I got used to the paper flow sheets and loved them!. Unfortunately the new vfs went live about 2 weeks ago. Now im looking for something just for my hourly documentation,without really having to double document on paper, yet to keep me organized to document what needs to go in hourly.

    thanks for the response
  6. 0
    nothing fancy here. I just take a piece of paper, fold in half, write report on one half then on the other half write the time from 07-19 down the side (7a-7p) and under each hour I write what meds are due & tasks (labs/line changes/dressing changes) and then I write outputs (chest tube/foley/drains etc) and temps when I take them. All our other vitals and drips/fluids are auto populated in the chart for us, when I sit down to chart I cross off what I put in from my list. Keeps me up to date pretty well. Been working for me for three years.
  7. 0
    Quote from umcRN
    nothing fancy here. I just take a piece of paper, fold in half, write report on one half then on the other half write the time from 07-19 down the side (7a-7p) and under each hour I write what meds are due & tasks (labs/line changes/dressing changes) and then I write outputs (chest tube/foley/drains etc) and temps when I take them. All our other vitals and drips/fluids are auto populated in the chart for us, when I sit down to
    chart I cross off what I put in from my list. Keeps me up to date pretty well. Been working for me for three years.
    This is similar to what I do. I fold a piece of paper in half lengthwise. On the front I write report and on the back is where I keep track of my hourly VS and I/O from 1900-0600, then I write Bedside Assessment, under that NCP(for nursing care plan) on the opposite side I write Note and under that 20, 22, 00, 02, 04, 06 and then spaces to write down the AM bloodwork results.
    Been doing this for over 6 yrs and works pretty good for me. IF a Dr wants to know VS, I make them a copy of my brainsheet(the backside with the VS info) and hand it to them as apparently looking up the info in the computer system(we use Meditech) is too hard for them.
  8. 0
    Quote from RNCCRN9706
    apparently looking up the info in the computer system(we use Meditech) is too hard for them.
    Haha. We just moved to a new unit and one of the main features the medical director was soooo excited about was the "iView". Basically it's a computer screen in the room that updates in real time with ALL the most recent vitals, blood gasses, labs, vent settings, fluid balances etc. No work required. It gets frustrating for the bedside nurses of course because the parents start obsessing over it (I work peds). Abnormal values are bolded in red and that always gets their attention whether the value is important or not.


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