Night shift not charting until 0000?

[rkitty198, BSN, RN]

Hello!

Question:

Does this sound right??

At our facility we have a mix of 8hour staff and 12hour staff. I work med/surg oncology.

We have three columns to chart under. Nights, Days, Evenings

I am a 12 hour and I was taught to fill in the Days assessment when I got on shift and then at 1500 to do the Evening assessment.

The 12 hour day nurses are paired up with 12 hour nights.

When nights comes in at 7pm they only fill out the Nights assessment. Since I did the 1500 assessment they rationalize that they do an assessment 8 hours after mine. They only do one assessment per shift.

I have no issue with charting two assessments. We dont have a policy on charting.

I just wonder if this is an issue with any of you? Do you working 12 hour shifts commonly fill out two assessments? Is this common practice to wait to do an assessment 4 hours into your shift?

Thank you

[Kooky Korky, BSN, RN]

Go by facility policy. If you do that, you can't ever be blamed for not following facility policy. Never mind what anyone does. It's not relevant.

Personally, I would think a nurse would want to chart an assessment sooner, as you say. But whatever.

[TooterIA]

Ditto to your facility should have a policy. But if your facility's policy is you dont have to chart an assessment until midnoc, I probably would still chart by assessment at 1930 or whenever I did it just to cover my ass.

[klone, MSN, RN]

We don't have to do full assessments q8h, just once per shift. We do have to do fundal checks and document lady partsl bleeding q8h. I know some nurses look at when the last q8h check was done, but I don't. I just do my full assessments at around 8-9pm, do fundal checks at that time, and then do another fundal check approx 8 hours later (4am-ish).

I just don't pay attention to who's doing what when and if one nurse is doing more than the other, as long as it's getting done within the parameters ordered.

[Orange Tree]

I work 12 hour shifts (nights) and chart one assessment. I fell fine charting any time before 00:00 on patients who are doing reasonably well. For patients who aren't doing as well, I make it a point to do a very thorough assessment very close to the beginning of the shift.

[NoviceRN10]

I work 12 hr shifts and I normally chart my assessments within one hour of starting (I chart as soon as I leave the pt's rooms), and always before administering any medications. It just doesn't seem right to me to give anyone meds before I document that I've actually looked at them. We only have to chart one assessment per shift, although one of the nurses I work with thinks that only applies if she doesn't chart until midnight.

[canoehead, BSN, RN]

The reason there used to be a 1500 assessment is because there used to be three shifts, and each nurse needed to assess the patient independently. Now with two shifts it makes sense that you do that initial detailed assessment and then do a systems based recheck with each set of vital signs.

[caliotter3]

I would feel uncomfortable not documenting an assessment done at the beginning of my shift, no matter what time I started. How is that going to look when you are on the witness stand? "Oh, I don't assess until midnight because the other shift just did it at three." Looks like you are not doing your job.

[NurseyBaby'05, BSN, RN]

Everyone does an assessment at the beginning of his/her shift, even if it's only four hours long, at my facility. Now, if I'm working nights and the person I'm following is thorough, I have no problem charting "Agree with above assessment" and then noting IVs, central lines, wounds, dressings, etc. along with any changes as my initial assessment. Four hours of a shift is awfully long to leave unaccounted for. If it's an uneventful shift, I use our hourly rounds, MAR, and other flowsheets to account for the rest of the shift. If there's a lot going on, I chart as needed on the nurse's note. (Everytime I call the doctor to address something, whether or not I received orders, what time Chemo/Blood/IVIG was hung and how the pt is tolerating it, what time it was complete, when the pt goes off the floor, changes in condition, etc.)

IMHO, those folks that wait until midnight are setting themselves up for a huge fall when the sh . . . . er . . . . .stuff hits the fan.

[tailwagger]

I work both 8 & 12 hour night shifts also on a med surg & oncology unit. If I work 8 hours I am required to do one assessment, if I work 12 I am required to do two assessments. For the second assessment if nothing has changed there is the option to choose "assessment unchanged" for each area such as neuro, cardiac, etc. 4 hours shifts also have to do 1 assessment. The same rule applies for daylight shifts.

[ChristineN, BSN, RN]

At my facility, officially we only have to chart assessments every 12hrs 0700 and 1900, so if you begin care at 1500 you aren't responsible for charting an assessment. However, I will typically do an assessment if I take over a pt mid shift.

[linearthinker, DNP, RN]

I always documented one head to toe, and timed it for when i actually did it, which could be anytime between 7p and 1a, depending upon how busy I was. Many times I never got to the head to toe for several hours, but I would assess and document problem areas in the meantime. I might not listen to bowel sounds if the patient is on the vent, but I did lung sounds, etc. I don't see an issue here at all.