I have a question regarding ICU documentation for HCA nurses and/or Meditech users:
How often and how are you documenting your pt assessments? Full head to toe "shift" assessments as well as "focus" assessments?
We have always done Q6 "Shift" assessments, and added in any additional focus or task list issues along with narrative notes as needed. Now, we are being asked to do a "Shift Assessment" at the beginning of the shift and Q2 "focus" assessments regardless of whether there is a change.
(Oh, and we don't have the F5 function available.)
So I'm wondering if this sounds like what other ICU's are doing and if this sounds right?
I've been trying to find any "standard" regarding frequency of assessments (on the BNE site, we're in Texas, AACN, AJCC, Google, anything) and I can't find anything and our facility doesn't have a policy for ICU documentation. Any help?