documentation

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    I am requesting examples of shift documentation of Nursing Assessments. I am hoping to develop a new tool for the hospital I work for. I would like an idea of how other hospitals document to make it easier for nurses and meet standards. Thanks for any help!
  2. 3 Comments so far...

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    WE USE A 24 HOUR FLOWSHEET WHICH INCLUDES ALL THE SYSTEMS, PAIN ASSESSMENT, ACTIVITY, IV ACCESS, POC UPDATES, RESTRAINTS AND APPETITE. WE ALSO HAVE THE CARE PLAN(S) AND THE NURSING NARRATIVE "NOTES". I HOPE THIS HELPS.
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    Joy, are you saying that your flowsheet can document all those restraint requirements? If so, I'd really like to see it. Seems like we have so many forms generated for restraints thateven the most meticulous of the nurses miss one from time to time. Not to mention the amount of overtime reconstructing the day at the end of the shift. Does it also cover the wound&skin documentation? If so where are you mounting the photos of the wound? Any help is appreciated.

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    TO CLARIFY FURTHER: THE 24 FLOWSHEET IS BRIEF IN THE AREAS OF SKIN, WOUND AND RESTRAINTS. WE ALSO HAVE SEPARATE FLOWSHEETS FOR EACH OF THESE TO STAY IN COMPLIANCE WITH DOCUMENTATION REGULATIONS. I THINK MOST FACILITIES CHANGE THEIR FORMS EVERY SO OFTEN BUT THERE'S NO WAY AROUND WHAT IS REQUIRED. COMPUTER CHARTING IS BECOMING MORE POPULAR. IT'S SUPPOSED TO CUT DOWN ON THE TIME NEEDED FOR CHARTING WITHOUT SACRIFICING THE INFORMATION. I HOPE THIS HELPS.


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