ICU documentation templates??
- 0Jul 19, '11 by nurscI am a recent graduate who just got my first job working in the ICU. We have online documentation and have to enter vitals q hr and do assessments q4 hrs. I was wondering if anyone had any good templates they go by for their documention? also if anyone had any templates or tips for report?!
Any tips/advice is WELCOMED!!!
- 0Jul 20, '11 by resumecprMy template begins with the patient sticker (top left) then from left to right, allergies, code status, age, attending MDs, weight, family names and contact #'s, then the password for giving info.
Mode Tv Peep F1o2
Things to do
Each heading has a few lines after for notes pertaining to the system
The right column goes by hour with about 1/4 inch of space to write what need to be done at that time. Included in this space is UOP and CT (chest tube)
Every 4th hour there is a space for temp and meal % eaten.
Hope this helps! Welcome to nursing!
- 0Jul 20, '11 by AaronInTheBayHi there,
I just started as a new graduate recently at a busy trauma center ICU.
We also use an online system to chart vital signs, I&O, assessments and nursing care. The program is called VisICU/ CareWatch; this is used in conjunction with the eICU.
I will try to upload my template later, but it is quite similar to the one shown above:
Patient sticker, diagnosis, allergies, code
History, history of present hospitalization
IV Fluids, Drips, IVs
Diet, BG, activity, weight
Skin, wound, drain
Psych social, family
Bottom rows contain time blocks
My template is set up in SBAR format; it works well giving report from as well as using when calling the MD.