Potentially dumb question about assessments...

[SubSippi]

Let me start off by saying that I know I should probably already know the answer to this, but I don't. I've been working on a tele/critical care floor for 2-3 months now, and I've asked a few of my coworkers, and have gotten varied, sort of vague answers on this.

My question is, are the head to toe assessments we document every shift ever used by anyone besides ourselves? Does anyone else ever go in and look at them, or are they ever used later?

I am not wondering why nurses do head to toe assessments at all. I get that, and I will often look at the previous nurse's assessments to see if anything has changed or if he/she caught something I missed. I guess what I'm wondering is if they are ever used in the bigger picture of the patient's care. I'm just curious, because I do so much documenting, but I don't really know where it goes or what it does.

[Dranger]

I would do my own assessment first so I am not biased then look at what the other nurse charted. It irks me when I can easily tell the previous nurse just copied and pasted when there are obvious changes...

[KelRN215, BSN, RN]

If the case goes to court, plenty of people will be looking at it. Other than that, no, there aren't any doctors reading your documentation or anything. Your hospital's QI department might be reading it too.

[SubSippi]

Thanks KelRN, that's exactly what I was wondering.

And to Dranger, I do an assessment and make a couple notes on paper, then when I have time a little later go and chart my assessment. When I'm charting, I bring up what the previous nurse put in, so I can see if there are changes/differences in opinion.

[GundeRN]

We have some assessments that are meant for other people to see but I don't know if they check it. We have for for wound care but I have put information in there about a change in drainage amount and need to reassess dressing needs and no one came to check the patient out until they got an actual phone call. Also we have a transportation assessment that is supposed to communicate if the patient needs a wheel chair or their oxygen/iv to go with them but often the person taking them to x-ray or where ever else finds us to ask. What drives me crazy is that now we have these new hand off sheets that are supposed to be in the room to update anyone coming to take them to another department about pertinent info. and no one looks at them. I feel like I am wasting my time with these documents.

On the other hand, I have a serious problem with how little documentation previous nurses give me on things that DO matter. No one documented a BM for a week? Nice. Sacral wounds that were obviously there on admission never charted. CSM's assessments not charted once and the patient is POD2. What really drives me crazy are communications had between nurses and doctors about plans of care that are never charted on. I have a person on ETOH protocol who is scoring high and previous MD's and RN's have discussion about these symptoms being related to another diagnosis and not to give ativan. YOU KNOW WHAT! MD, DC THE PROTOCOL THEN PLEASE! RN IF DOCTOR DOES NOT DC, NURSE NOTE THE CONVERSATION PLEASE!. I am on the night shift with no doctor present. If this guy is in withdrawal and I do not act and he has a seizure, how does this look for me? What is to stop them from throwing me under the bus and saying said conversations never happened?

Sorry, end of rant. I guess I would say I am more bothered by missing documentation, that having it to the excess.

[GundeRN]

Thanks KelRN, that's exactly what I was wondering.

And to Dranger, I do an assessment and make a couple notes on paper, then when I have time a little later go and chart my assessment. When I'm charting, I bring up what the previous nurse put in, so I can see if there are changes/differences in opinion.

This is exactly what I do

[nurseprnRN, BSN, RN]

You bet other people (including physicians, at least the smart ones, if they know your notes will be worth spit) are reading them, people you never thought about.

One of the very best compliments I ever rec'd from a physician was that he loved my documentation because he could really see what the patient looked like by reading it (bless you, John Mehigan, vascular surgeon, wherever you are). That is what you are aiming for.

The best way to think about nursing documentation is to think first about what medical records are used for. Quick! How many things can you think of?

1) Communications between staffers and disciplines

2) Legal documentation of events, assessment, and care

3) Supporting billing and insurance reimbursement (and that becomes your paycheck)

4) Clinical research

5) Education

6) Quality improvement/risk management

Gold star if you can think of some more!

The point is that you have to keep a lot more in mind when you write your notes and document your meds. All of those folks will be reading them sometime and counting on you to be accurate and descriptive. If your nursing documentation class had that in mind, by all means, take it to heart and use it every day. If it didn't, consider a creative writing class that teaches you how to see beyond the obvious and how to use good English to describe it for the reader. I can tell you at least one excellent doc, a lot of bean counters, medical and nursing researchers and academics, and many lawyers and nurse legal consultants will appreciate that. :)

[MomaNurse]

Usually the computer assessments are set up so reports can be pulled, data analyzed, trends identified and education developed. There. Potentially dumb answer.

[MauraRN]

There are no dumb questions.

[dudette10, MSN, RN]

Where I work, no one but nursing can see the assessment flowsheet in the EMR. Not even the docs. That's why my narrative notes can appear to be double charting. The residents have told me that they do indeed read the nursing notes, so I want to make them as useful as possible. I do not include narrative on anything that is WNL AND which is unrelated to the admitting diagnosis or noted comorbidity (both criteria must be met for me to not include it). I look at the previous assessments to review trends.

[JBudd, MSN]

It's a good defense mechanism, but I really just want to do them so I know a baseline for the shift. Working in the ER, I don't usually have a recent previous assessment to look at, but for a bounce back pt it really helps to know what they looked like last time.

Been deposed a couple of times, the more I charted the more I was able to state care or what I did (because as we all know, can't intervene unless we've assessed first! :) )

[Meriwhen, ASN, BSN, MSN, RN]

I look at the previous assessment; I like to have an idea of how the patient was during the last shift, so from my own assessment, I know if things are currently better or worse.