Paper charting assessment in isolation room

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Specializes in Acute Care Psych, DNP Student.

Recently, I had a patient in an isolation room on contact precautions due to MRSA. So I could not bring my clipboard and assessment forms into the patient's room. We don't have computer charting in the room. My classmates said that you have to do the assessment and just remember all the data to write down later when you're out of the room.

I don't believe that we can accurately memorize everything on the assessment form and write it down later. BP, HR, RR, temp, radial pulse, pedal pulse, apical pulse, pupils' mm, color of urine, skin turgor, degree of edema, skin condition and locations, staging of ulcers, CMS, breath sounds and location, dressings assessment, FSBS result, etc. I do NOT believe that we can honestly remember all this data including the exact numbers accurately and write it down later.

What do you all do?

I have actually had someone stand outside the room and write down what I call to her.

Specializes in Acute Care Psych, DNP Student.

Every classmate I asked said they remember it all to write down later. I think they have to be fudging part of what they write down.

Well, I have had so many patients in isolation I have a system down now, LOL. I can generally remember my assessments quite well but you are right that it is hard to remember all the numbers for T,P,R, BP, FS etc accurately. What I do is write the info down on a piece of paper in the room with a pen or marker that is already in the room. Then simply place the piece of paper in a place where you can see it from outside the room as you leave before you de-gown and glove and wash your hands. I usually put mine on top of the dirty linen or trash receptacle and then throw it away my next trip into the room. You could even place the paper on the floor if you had to.

Then once you are outside the isolation room you can view the numbers and accurately write them in the pt's flow sheets. :)

Specializes in Acute Care Psych, DNP Student.

Thank you Sue & Mixy!

If there is a window on the door I would just write my assessment info on a paper towel and tape it to the window so I can see it from the other side, then just take it down next time I went in.

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