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?
Aug 21, '12
by Esme12, ASN, BSN, RN Senior Moderator
Your documentation should be driven by acuity and drips hanging. Your facility should have IV drip policies that state where the drip can be hung and how it need to be monitored. I am always confused by facilities that have no set policy for admission or discharge criteris to the care area and policies for the care of the aptient in tha tarea.
The standard of care is usually a head to toe assessment q 4 hours with a more focused assessment at least every two. MOre frequent as the patient condition warrents. Remember this patient and the insurance company is paying big bucks for them to be there becasue they require that higher level of care. I did find this for you....I hope it helps.
Standards for Frequency of Measurement and Documentation of Vital Signs and Physical Assessments
Examples of ICU policeis....
http://rmh-ics.org/downloads/icu_pol...ted to ICU.pdf
Last edit by Esme12 on Aug 21, '12