Assessment and documentation guidelines

  1. 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!
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  2. 6 Comments

  3. by   NurseGirlKaren
    In my facility, policy for ICU/CCU patients is head to toe assessment done and charted q4hrs. For more unstable patients (I'm thinking neuro checks) usually the docs order q1h or q2h. Vitals q2h but more often if needed according to nurse's judgement.
  4. by   BadBird
    I am used to head to toe assessment initially, q1hr VS unless on a drip then Q5-15 min. Chart Q1hr for updates, interventions, and outcomes as needed. Now I am getting used to computer charting Q1hr and when needed. I have to admit I still prefer the paper flow sheets. Also chart at least Q4hr. cardiac rhythm, lung sounds. It just depends on the acquity ,stable patients maybe chart q2 hrs, unstable is continuous.
  5. by   Stargazer
    Thanks guys! I'm reassured that the guidelines I had in mind weren't too stringent after all.
  6. by   carmel
    anybody has an good example of a healthassesment assignment,,,could u please forward to me...chillarys@yahoo.ca
  7. by   Renee' Y-Y
    If the patient is still critical enough to remain in the ICU (vs. tele orders & no bed, for example), head-to-toe should be minimum Q4H. You might be able to find some additional information or resources on the aacn site...www.aacn.org.
  8. by   IamRN
    Quote from renee' y-y
    if the patient is still critical enough to remain in the icu (vs. tele orders & no bed, for example), head-to-toe should be minimum q4h.
    i agree. if the patients can get away w/needing an assessment (head to toe) every eight hours, then they belong on the floor.

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