Documenting Nursing Process

[-Emma-]

Our nurses have been dealing with a lot of problems with our present way of documenting our nursing process. It's involved, all hand written and confusing. I was wondering if some of you out there can share what form of nursing process documentation you use. We have a care path, I've also heard some places using a kardex. Our care path is four pages front and back. The cover has patient ID, allergies, history, contacts and fall risk. Inside has two pages where for six days the nurses prioritizes the nursing diagnosis, interventions and goals. Then are two pages for six days of ordered labs, active orders (IV fluids, diet, activity, etc.). Then are two pages for education. The last pages is for treatments (dressing changes, ventilator weans, etc.). After the allotted six days, we trade that care path out for another care path. If the patient had a medical care path and codes on the floor to become an ICU patient, the medical care path is changed to an ICU care path.

Any thoughts, suggestions or "here's how we do it" is greatly appreciated. Thank you all.

[Daytonite, BSN, RN]

What you have are care paths or critical pathways. They have been around since the mid-80's. Basically, they were orginally a timeline that is a projection that describes, in advance, the care you anticipate to be providing to the patient. There should have been some instruction when each nurse was oriented to the job as to how these critical pathways were to be used. They are not meant to be rigid. There is supposed to be room to customize and individualize them. Have you spoken to someone in your nursing education department about guidelines on how you are to document on them to clarify the confusion?