Anyone use meditech in NICU, or at least chart by exception

[iHeartNICU]

Ok, so I'm a brand new RN in the NICU and I have a question about documentation. In the shift assessment you have the within defined parameters (WDP) and you are only supposed to chart by exception so if you answered that one of the systems was not WDP you would chart on exatly what is abnormal. Here's where my question comes in. In the reassessment screen it doesn't have the WDP so do I still treat it as charting by exception or should I be chartin normal things too?

Also, I see some nurses writing things in the comments section such as "suction equipment functional at bedside." Ok, that sounds fine but then some nurses have told me I shouldn't even put that because at the end of the shift you sign off that standards of care thing and that is saying you follow standards of care which includes all that safety stuff....so it would be like double charting if you actually wrote that out. They say that not only is that double charting but since we chart by exception it's like saying that is wrong to have the "suction equipment functional at bedside." Sorry if that doesn't make sense.

Help, I'm so confused. I just want to do this right so nothing ever comes back to bite me in the behind. Thanks in advance.

[SteveNNP, MSN, NP]

This sounds like a great question for your manager, clinical educator or senior staff. Guidelines on standard of care charting are different from facility to facility.

[RainDreamer, BSN, RN]

I agree with Steve. This really should be something you need to talk over with your preceptor and other educators/managers/mentors on your unit. This is just way too specific for us to answer here ..... every place has different charting programs and policies.

Go to your preceptor or other mentor, a good nurse, that you trust .... and ask them how they do it, and ask them to tell you why they do it that way.

[hikernurse]

We chart by exception and it's interesting to see the many ways people chart. I'ved seen 2 full pages on patients full of things like, "baby burped after two minutes of patting back" and "after bath, baby was given a clean diaper" (I'd hope ).

I've also seen "1830, no issues through shift" and nothing else.

I'm in between. I try to chart at least every 3 hours, but sometimes I don't have much to say when I have a very stable baby.

We were told in orientation that from a legal standpoint, less is more.

[acerila]

We were told in orientation that from a legal standpoint, less is more.

I've been told that before (the more you write the more they can pick apart later) and I tend to follow it. I'm not saying I'm totally not going to chart certain events but for example: We have one baby on the unit that's been there forever. She has been doing alright for a while but one day she totally crashed and had to be intubated. The whole thing was a mess the doctor on call was in the middle of putting in a line on another baby, so we had to call another md. The whole time the baby was being bagged, sats were in the 20s, the heart rate wasn't coming up too quickly either and he had trouble intubating the baby and it took him a few attempts. The nurse that had the baby was charting every single little thing about this whole mess (this baby's family was totally difficult as well and would have sued in a heart beat) while I personally would have just charted the sats&heart rate and that the baby was being bagged, md notified and the baby was intubated with this size tube and this location and breath sounds were noted. I don't think it's necessary to sit there and chart that it took a million attempts to get the tube in etc.

[texas2007, BSN, RN]

My facility charts by exception. I always make sure to write a little about anything safety wise. I usually chart something along the lines of "infant received in (type of bed). alarms checked per protocol. bag and mask at bedside in working order. suction set up and running ___ mm hg. __ lines running with X fluid at __ rate, site appearance, cpap/vent settings, og/ng tube secure at __ cm. any other things of note the patient has. Assessment as charted. (state of infant) at this time." Some nurses, including my preceptor have told me all that is a waste of time since pretty much all of that is already documented somewhere in the flowsheet but spending the extra 5 min. to write it out and recheck things makes me feel much more secure and on top of what I'm doing.

[NeoNurseTX, RN]

My facility charts by exception. I always make sure to write a little about anything safety wise. I usually chart something along the lines of "infant received in (type of bed). alarms checked per protocol. bag and mask at bedside in working order. suction set up and running ___ mm hg. __ lines running with X fluid at __ rate, site appearance, cpap/vent settings, og/ng tube secure at __ cm. any other things of note the patient has. Assessment as charted. (state of infant) at this time." Some nurses, including my preceptor have told me all that is a waste of time since pretty much all of that is already documented somewhere in the flowsheet but spending the extra 5 min. to write it out and recheck things makes me feel much more secure and on top of what I'm doing.

Most people on my unit do this little opening note. I now just assess everyone when I get on and write something really short..and try not to double chart.

[WildcatFanRN, BSN, RN]

On the unit I was on, we did a complete assessment/charting q4h if your kiddo was NPO and was a q2h. Meaning 1st assessment was full, second was cluster care, 3rd was full, etc. I never did get a complete answer as to using the "no change from previous assessment" part. Safety assessment was done with each assessment, at least I would do so. Also developmental care, respiratory positioning, etc. Only time I had to chart an actually note was to report how we received a new admit from newborn nursery.

[babyNP., APRN]

Interesting. We do computer charting at my facility and it's a TON of charting. Unless they're really stable and looked good at the last assessment, we have to do a full assessment q3h or q4h if they're feeding or not. Sometimes I feel like I spend too much of my shift clicking on things!

[Preemienurse23]

We do assessment q shift, either 8/12. If I have a stable baby, I dont mind doing one. If I have a sick baby or big changes I will do 2 if I'm working a 12. I chart enough so that in 15-20 years there is lawsuit, I can look back and have an idea of what happened that day.

[RN4Little1s]

Wow, once a shift! That's very interesting. How often do you do vital signs? All I can think about when I here this is the NEC babies that have their poor little bellies blow up in a matter of hours when they were stable just before.

[NeoNurseTX, RN]

Wow, once a shift! That's very interesting. How often do you do vital signs? All I can think about when I here this is the NEC babies that have their poor little bellies blow up in a matter of hours when they were stable just before.

We assess once a shift, too, which I think is really odd considering we assess the newborn nursery babies q8. We do girths q6 though.