We do a complete head to toe Q4H and a focused assesment Q2H. That is we document on the main issues for the focused assesment. And only if something has changed, because we have the option of saying "no changes to previous assesment" if it is the same nurse and same shift.
We do charting by exception. We chart the detailed assessment at the beginning of shift, and only change things that change during shift. I love my electronic charting system, I feel like I'm able to focus ont he patient more, plus we just have to double click for vital signs to enter. So instead of spending all this time charting vitals, i can focus on what I need to do about those vitals.
We chart Head to Toe Q4, Chart changes when they happen, Rounding assessment Q2. VS @ 15, then Q 30, Then Q1 hour. Some hospitals have the new systems that allow VS documentation by the click of a button that are slaved over from the monitors, depending on pt needs, to be done as often as needed.
Three ICU's in my hospital and three documentation ways:
NeonatalICU - Full assessments q3-4 depending on the kids "care" schedule
PedsCardiacICU - Full head to toe once, then neuro/resp/CV q4
PICU - Full head to toe once, neuro q4 and other changes q4
Q2h head to toe assessment, hourly neuro checks if needed. VS q1-2h
**We have a hybrid of electronic/paper charting and I swear that I spend more than 50% of my time charting. I feel like this electronic charting makes my work life he**. Charting was much faster when it was all paper. (I've heard from others that this is due to the incomplete system our organization purchased though.)