Documentation - Consistent throughout?

  1. We are looking for answers for standardizing nursing documentation throughout our hospital setting. We have patients coming in for blood transfusions for example in both our same day surgery units and our inpatient units, as outpatients and then being discharged that same day. We need to know if you are doing full admission assessments on these "special" patients that are coming for OP nursing care.?

    We want the care to be consistent for patients across the continuum, but we don't want the nurses to do extra documentation work if they don't need to.

    Can you let us know what you are doing at your facilities?
    Looking forward to your reply.
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  2. 3 Comments

  3. by   CATHYW
    I don't do hospital work anymore, but could you not let one person do the head-t-toe, initial assessment, and then any other nurse would do a head-to-toe, similar to what you would do at the beginning of your shift. The first nurse could document any changes from the previous day related to health, caregivers, change in home situation or doctors, etc. The second, and subsequent, nurse simply asses the patient thoroughly, and documents the patient's LOC and demeanor, lung, heart, and bowel sounds, and pulses in all extremeties, as well as the condition cath site(s), plus any of the patient's perceived changes in conition, or complaints. In a person with a dialysis shunt, the thrill and bruit would be documented. Document all meds, and I & O.
    As I said, I am probably speaking out of turn, but these are the kinds of things that would be important to me as a receiving nurse, or as a patient.
  4. by   RNatlast
    when we have someone coming in for a transfusion or ABX. infusions, we have a "day of event" form that we use.although it's supposed to be quicker/easier to fill out, i think the only thing easier about it is the pt. profile part. we still have to do a complete head-to-toe assement. hope this makes sense,it's hard to describe all the paperwork without visuals!!!
  5. by   nightingale
    I moved this thread to the General Nursing Discussions Board..

    B.

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Documentation - Consistent throughout?