Documentation in ICU - page 2

I have a rather stupid question for my ICU nurses but what exactly do you write nursing notes on? We use VAR charting and I do that well, but when there is not a variance I don't know exactly what I should be charting on my... Read More

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    Quote from eCCU
    EPIC is the best so far i have seen:-)
    We are going to EPIC next year. It will be so nice not to have 2 or 3 systems to look up labs, and narrative chart, + paper chart.

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    You chart as much as it takes to make you comfortable. Charting has also saved my butt. There was a suite against every nurse, Dr, and the hospital on a patient and I was the only one who was not liable solely due to my charting alone. I was told that by an attorney! So, chart defensively!!!! I teach this to all new nurses. You make sure that you document as though you were going to be sitting in court with this patient. What do you think you should chart? If you do this, you will document just the right amount. Statutes are usually about 7 years. Will you remember everything that has gone on 7 years ago? If you didn't chart it, you didn't do it. So, be careful. NO ONE will be standing behind you backing you up! You will be alone! So, be careful. Those who are wanting you to do a narrative are simply trying to keep you out of court.
    HappyWife77 likes this.

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