Meditech and ICU Assessments - page 2

by KymmD77 10,571 Views | 21 Comments

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... Read More


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    Quote from KymmD77
    Curious, what is a CC assessment? Critical care? Or is it something new?
    I forgot to mention our Meditech version is the old DOS from 1996. I know there are newer versions available, which I hear from travelers and agency are much more user friendly. I'm wondering if you guys are stuck in the dark ages as well? Or are you using a newer Meditech?
    Its the old archaic DOS based version. And yeah CC is critical care. The names I stated are what it says when you choose Assessment from the status board. This Meditech we use is the oldest charting system I have ever seen. I'm with HCA as well.
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    Interesting! We do qshift full assessments then q4hour focus assessments on any changes. neuro checks anywhere from q15min to q4hr depending on patient. pain assessments prn. VS & IO's, titrations on paper q15min to q1hr depending on patient.

    meditech is so archaic.

    we have the paper order sheets and paper VS flowsheets/drip flowsheets, then computer charting and med scanning... do you too?
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    Blah!! This is my first job with an HCA hospital and Meditech and so far it's awful!! So unuser friendly than what I am use to!! We do one a shift head to toe assessment (8am) then 12 and 1600 pt notes as reassessment. We have no option to copy and paste, I guess that's what the F5 function a previous poster had mentioned was. The only thing we do document under a reassessment is skin. Skin Reassessment is mandantory under the reassessment section. We also document Q4 hour cardiac telemetry strips both on paper and on the computer.
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    We do also have paper flow sheets for drips, VS, pain assessments, and Glasgow scale. We then put I&O totals in the computer from the flow sheets. VS are also transferred over via the monitor section too. Seems like a lot of duplication in charting.
    gypsyd8 likes this.
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    We document every two hours. If there is no change, we put NC in the field
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    anyone has a manual for meditech DOS? I just started using this interfaced, but I was only given a small booklet.
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    Wow, you chart your IV site and skin assessments every 2 hours? Why's that?
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    We have MT6. I was taught to chart on everything at least once on my shift, with the exception of the vital signs, vent checks, CVP (these must be done every 4 hours) on the computer. We still have to chart the vitals every 1-2 hours on the flow sheet, along with the CVP and vent checks. I hate double documentation! Also, we have to do a modified assesment every 4 hours (neuro, cardio, resp assessment). It's a lot of charting and I hate it!!! Wish I could spend my time actually caring for my patients than doing charting. Anyway, I know it'll keep my butt out of jail in the long run!
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    We're just starting with MediTech and I agree with the previous poster--it is certainly NOT user-friendly. I've used another system at another facility and it was great! MediTech is very cumbersome--when vitals, labs, etc need to be charted for meds you have to click to four different areas just to chart all the info needed. At my other facility all the info required was right there on one page. Still clicking but not to different pages. What a waste of time when I could be caring for my patients!! :-(
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    I'm a travel nurse and the hospital I'm at uses meditech. I like it, but I do not like the "nursing note" aspect as I think it is double charting. If we work 12 hours, we chart a full assessment twice. As stated before, there are the q2hr and q1hr vitals, ect, or any changes.
    Quote from KymmD77
    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?


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