Just thought I'd see if other ER nurses have to do this?
In our ER, nursing management wants us to put in an RN note every two hours about the status of the pt - even if there is no real change in status. Plus they want us to chart why we are giving a med (not just in the MAR) in the RN notes.
I understand charting the initial assessment and work-up, but really, every 2 hours, plus why we are giving a med? Management tells me that it's to protect me in the court of law just in case something goes wrong. But I'm like, I have to be out in the ER working up patients, helping other nurses, taking patients to CT - I can't chart on all of my patients every two hours. Am I being too resistant, or are they being unrealistic?
This is the only ER I've ever worked in, so I'm curious if this is standard practice or what?
even for my stable pt's its not a bad idea to at least chart the vitals and something short relating to the presenting complaint ie: pain free, awaiting CT etc. Even if theres nothing significant to report it shows that you have at least laid eyes on the patient. Typically I have 5-6 patients and dont have a problem charting for each patient every couple of hours. Of course sometimes you get one patient taking up all of your time so this doesn't always get done but I try my best. Our ER doesnt have a MAR like the wards do so every med we give is written in the nursing notes along with the reason for it ie morphine 5 mg IV for 6/10 pain.
It's q2 (not just a simple note but vitals) in our ER as well. It's actually saved my rear a few times when a family member complained to my boss that nobody had talked to them or come near them for "over 4 hours". In reality they were there exactly 2 hours from the time they walked in to the time they left without being seen and I had charted 3 times in that 2 hours. I chart at least every 2 hours and if I go into the room in between that time I chart if there is any change in patient status.
We try to revital all patients at least every 2hrs (usually only a concern for WR pt's ). I do not regularly see this as a problem once they get back to a room because most of the RN's are really on top of their pt's status. On crazy days the WR pt's might get 3 sets of vitals before they make it to a room (nonacute pt's of course).
I don't really see a problem in charting what they med you are giving is for if it is a PRN med (ie. antiemetic or pain med) other than that I think it's a little unnecessary.
Our boarders get notes at least every 2 hours. Triage level 3 patients and higher get notes and vitals every hour and criticals at least every 15 minutes. Everyone gets vitals and notes within 15 minutes of discharge and vitals and notes after interventions that will change vitals. Waiting room patients get vitals and a check at least every 2 hours, more often if they need them. We work hard to keep our patients evaluated. Sometimes the frequency makes a huge difference in outcomes. This is with about 45,000-50,000 patients per year through our ED.
I can only assume that the OP must be referring to situations in which the ER patient is in a 'holding pattern' awaiting a room for admission or diagnostic test results so that he can be discharged. Otherwise, charting frequency should be based on the patient's acuity -- stemming from the inital triage classification. Very acute, unstable patients should have nearly continuous entries in their ER record, because charting should reflect the actual patient treatment.
As for meds - true ER patients don't have any "routine" med orders. They are either being given a med in order to keep up their usual (home) meds, PRN for acute symptoms such as pain/HTN, or as an initial dosage for something that will be continued as an inpatient if they are waiting for a room. I would think that you could negotiate to limit charting in the nurses notes - just for PRN or one-time meds. PRNs should always have additional assessment data, including pt's response & one-time meds may need an explanation like "to avoid interruption of home med schedule".
I agree - charting can be a real pain. I have had the experience of being deposed as part of a lawsuit. I learned the value of making sure the patient care record to actually reflects the care I gave -- if it is ever called into question in the future.
we are required to chart q1h and were as well in m/s. it doesn't always happen that way, but we are expected to do so. we are expected to do VS q1h on all pts. q30min on chest pain/very SOB pts. q15min for criticals. and the VS can be adjusted based on pt sx/triage protocols. VS are to be done before and after each intervention (medications mainly), and charting every 15min on psych/suicidal pts. I feel it is fairly standard, and should remain this way. If charting is only done q2h, then why is the pt even in the ER? If it isn't charted, it isn't done. May just be a far stretch in some ERs, but I try to keep up with my facilities standards. I am not always able to get in to my pt every hr for VS, but I keep a BP cuff and pulse ox attached to them with a default setting to cycle every hr. makes life much easier!
We have to chart a pt note every hour; round every hour and do a reassessment every 4 hours. I always make a note when I give a med so I can reassess the pt's response (IV meds reassesment in 1/2 hour and po meds in 1 hour) to the treatment.
We have what is "expected," but that's not always officially written in a policy. Here's the rough breakdown for us:
Emergent Class I (e.g., big trauma, STEMI)--primary nurse at bedside almost the entire time, charting every action, med, VS, etc. I'd call this one every 5 -15 min.
Emergent/Urgent Class II (condition guarded)--every 30 minutes, charting and VS, including rhythm if a cardiac patient.
"less urgent" Class III--every hour if VS stabe on admit. VS charting on these is much more subjective, but I generally do them every couple of hours if they are on the monitor already. Why? Because 120 minutes it the longest time on my BP cycle program! Some of these can go without VS for 4-8 hours.
Fast track/Class IV--Focussed charting, VS may not be taken after initial unless condition or med warrants it. But we are still expected to SEE the patient at least hourly (they shouldn't be in the room this long, anyway). Our nurses notes sheets for this group just don't have the space for much charting.
Hold overs for rooms upstairs--VS per admit orders or based on drips running. Still expected to check on them hourly. The entire hospital is doing hourly rounding, so unless they're going to ICU, that's considered standard.
Hospital policy is for "charting by exception" and hourly rounding. However, when I worked on the tele floor, the "unwritten" standard was charting every 2 hours.
Granted, sometimes all you can chart might be "no changes, awaiting labs, denies needs/complaints" or something of that nature. Our ER is BIG on keeping the patient informed.
janette87
26 Posts
even for my stable pt's its not a bad idea to at least chart the vitals and something short relating to the presenting complaint ie: pain free, awaiting CT etc. Even if theres nothing significant to report it shows that you have at least laid eyes on the patient. Typically I have 5-6 patients and dont have a problem charting for each patient every couple of hours. Of course sometimes you get one patient taking up all of your time so this doesn't always get done but I try my best. Our ER doesnt have a MAR like the wards do so every med we give is written in the nursing notes along with the reason for it ie morphine 5 mg IV for 6/10 pain.