Meditech and ICU Assessments

  1. 1
    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?
    Last edit by Joe V on Aug 22, '12 : Reason: spacing
    Joe V likes this.

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  2. 21 Comments...

  3. 2
    The hospital I work at has Meditech...In my ICU we document Q2H and PRN. 3 head to toe assessments, 0800, 1200 and 1600. Q2H assessments which are focus assessments like IV sites, Neuro assessments, Skin, etc. are done at 1000, 1400 and 1800. Narrative notes are done with head to toes and PRN. For me it just becomes routine and I'm just used to it. It was the way we were trained on our unit, so most of us don't have a problem with it. I think it's important, seeing that any one of the assessments or conditions can change at any moment.

    I hope this helps. I mean with a patient load, it is possible. It only becomes difficult if we ever, which is rare, take a third pt.
    happyinillinois and Esme12 like this.
  4. 0
    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.... to ICU.pdf
    Last edit by Esme12 on Aug 21, '12
  5. 0
    Thanks for the response. We used to do Q4, but at that time we had F5. When they took it away we switched to Q6. So I'm just curious if you can F5 your 2nd and 3rd assessments?
  6. 0
    Thank you for the article! I need articles like this and I'm also looking for policies from other facilities.
  7. 0
  8. 0
    Thanks Again!
  9. 0
    We do CC Shift Assessment at the beginning and then CC Shift Reassessment Q4. CC Frequent Assessment Q2, and at least 1 nursing note Q2. Obviously any additional assessments and notes as the pt and their condition warrants. Vitals Q1, I&O Q2. These are for the ICU patients.

    And it sounds like you are doing the full on assessment documentation each assessment (previously Q4, now Q6?), judging by the F5 comment? We use the CC Shift Reassessment where you document if there are any changes to each particular area, Neuro, Cardio, etc, and if you answer Y then it takes you to that actual assessment, otherwise if you put N there is no need to document anything else as there are no changes.
  10. 0
    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?
  11. 0
    My facility doesn't use meditech but we have all computer charting (cerner).
    In the ICU I work in now we document like this:
    q1: vitals, I&O, drips, lines/tubes/drains
    q2: Neuro, ADL's
    q4: Pain

    8am we do a full head to toe assessment, 12&4 we do (on all patients) cardiac/resp/neuro and being a cardiac icu we do a very detailed cardiac assessment every 4, then with the 12 & 4 we can also do any focused assessment particular to a certain patient

    We have no function to "copy/paste" an assessment, each one must be charted new

    We do a nursing note on every problem the patient has as well as an overview of the shift, every shift

    And then there is all the other charting, meds, physician notifications, significant's never ending!

    I've gotten it down to a pretty good routine though and I almost never stay late because of charting.

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