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.
We assess NICU-status babies q3h (and do vitals q3h), and we assess stepdown babies qshift. We do sometimes do "hands-off" every other when a baby is really touchy, but for the most part, we are checking on them much more often that that.
We do all computer charting, and there is usually not a need for an actual progress note, unless something out of the ordinary happens that you want to comment on. We have a flowsheet in our charting system that we follow, and we don't do much paper charting at all. I really like our system...it's quick and efficient!
NICURN29
188 Posts
We assess NICU-status babies q3h (and do vitals q3h), and we assess stepdown babies qshift. We do sometimes do "hands-off" every other when a baby is really touchy, but for the most part, we are checking on them much more often that that.
We do all computer charting, and there is usually not a need for an actual progress note, unless something out of the ordinary happens that you want to comment on. We have a flowsheet in our charting system that we follow, and we don't do much paper charting at all. I really like our system...it's quick and efficient!