Hi, all. Due to some consistent problems with complete and timely documentation--of both assessments and
interventions--on our ICU patients, I have designed new ICU flowsheets for our facilities and would like to take the opportunity to set some guidelines on assessment and charting.
For example: Head-to-toe assessment at least q8 hours; pts admitted with cardiac or respiratory dx to have CV/resp. assessments charted at least q4 hours; unstable neuro q1hour; stable neuro q2 - 4hours; and so on.
I want to set reasonable guidelines that won't come back to bite us in the butt, i.e., nurses being cross-examined in court as to why they "weren't following institutional guidelines" because the guidelines were too stringent or not realistic to begin with.
Do you have these kind of guidelines in your unit, or is it just "per doctors' orders"? Does JCAHO have specific requirements for ICU charting? (I searched their website, but couldn't find what I was looking for.)
Any advice, help, comments, links appreciated. Thanks!