Charge Nurse Rounding

Nurses General Nursing

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Our charge nurse rounds on each patient daily. Usually they asking pt questions about specific topics like pain and if they are being rounded on hourly. The charge will now need to make a note regarding the rounding. How do you go about doing that especially if the patient has a complaint about a staff member or physician? I suppose I am looking for appropriate and inappropriate note examples to help my charge nurse out. I appreciate any help anyone can offer.

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What charge nurse has the time for that? Ours are often too busy to get their required work done after they are done helping us, shoot sometimes they even get a few patients of their own.

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Specializes in Ambulatory Care-Family Medicine.

Daily round on patient. Patient able to identify side effects of X medications. Patient received bath today/yesterday. Patient has further questions regarding X diagnosis, will alert primary physician to discuss further on rounds.

No need to document staff complaints in the medical record, those need to go to management through whatever in your reporting system you use. Just document the medical side of things in the chart, whatever specific topics the charge is supposed to be checking on. I used baths and side effects because that is what our management is currently focusing on.

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Daily round on patient. Patient able to identify side effects of X medications. Patient received bath today/yesterday. Patient has further questions regarding X diagnosis, will alert primary physician to discuss further on rounds.

No need to document staff complaints in the medical record, those need to go to management through whatever in your reporting system you use. Just document the medical side of things in the chart, whatever specific topics the charge is supposed to be checking on. I used baths and side effects because that is what our management is currently focusing on.

Yes! Complaints about staff members should be relayed in a far less formal manner.

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Specializes in SICU, trauma, neuro.
Daily round on patient. Patient able to identify side effects of X medications. Patient received bath today/yesterday. Patient has further questions regarding X diagnosis, will alert primary physician to discuss further on rounds

How many pts does this note have to be written on? Dang. I don't work charge, but I have never seen one who would have THAT kind of time. :eek:

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Specializes in Ambulatory Care-Family Medicine.

Our unit splits it between day and night charge. 28 beds, day does 18-20 and night does the rest. They actually have a flow sheet type thing built in the chart where they just have to check boxes and it will put most of the note together for them, then they can free type anything extra that they want to add. For the day charge it takes about 45 minutes to do the rounds and document them but they do a few throughout the day instead of all at once.

When they go in the room they literally say Hi I'm Susie, the charge nurse today. I just wanted to come check on you and see how you are doing. If patient brings up a complaint then they address it accordingly but most of the time the patient says something like oh I'm good just ready to go home.

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There are definite times when this is hard to do for the charge. They general try to split the floor with the NOC PCC. Several them will round as they are helping to answer call lights or assist with med pass or whatever. There are days when it has to be difficult for them to do. Rounding right now involves going around with a clipboard with focused questions but the PCC is being asked to create a note in the chart. Seems like more work, but we will see how it plays out.

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Daily round on patient. Patient able to identify side effects of X medications. Patient received bath today/yesterday. Patient has further questions regarding X diagnosis, will alert primary physician to discuss further on rounds.

No need to document staff complaints in the medical record, those need to go to management through whatever in your reporting system you use. Just document the medical side of things in the chart, whatever specific topics the charge is supposed to be checking on. I used baths and side effects because that is what our management is currently focusing on.

This was very helpful. Thank you!

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How many pts does this note have to be written on? Dang. I don't work charge, but I have never seen one who would have THAT kind of time. :eek:

Our unit can hold 25. I can see this being a bit of an issue when we are full and have high turn around on beds.

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