Charting question

[umcRN, BSN, RN]

Hello! I just have a question about how you do charting in your PICU. I work in a NICU and today floated to the PICU (where I've been trained but forgotten this interesting fact about their charting). In the NICU we do and chart full head to toe assessments q3-4 hours depending on how often the baby has hands on time. In the PICU at my hospital they chart a full head to toe at 8am and then Neuro assessments q4 hours (unless otherwise ordered depending on condition). So my 2 mo old infant today, sick with the flu and completely neurologically appropriate was supposed to have a neuro assessment charted q4hrs but I didn't need to document a resp assessment q4...even though we had pulled a chest tube that morning, were continuing to actively do chest PT and suction him, and he was still on 4L O2 & around the clock nebs. Just seemed strange to me...I ended up charting the resp assessment q4 anyways, what if he had done poorly and nothing was charted?

Anyways how do you do it??

[NotReady4PrimeTime, RN]

On our unit we use PICIS Critical Care Manager software; we're expected to document head-to-toe assessments at 0800, then update any changes in assessment data as they arise. At 1200 and 1600 we're to document as an event that a head-to-toe assessment was performed and either that changes were noted as previously documented or that no changes were noted. I update as I go, so if I'm titrating pressors, that's documented when I do it (or close to), if I change a dressing that's documented once I'm done, if I d/c an IV, foley, central line, NG or anything else that's documented as soon after as possible, as an event in our software. Regardless of what the unit standard is, if there are specific changes that occur or specific assessments that are required by the patient, you should be documenting as you go.

[RNNPICU, BSN, RN]

We do a head to toe assessment at the start of the shift and then chart if there has been a change, for example pulling a chest tube would definitely need a reassessment. But if there is no change in your assessment later, then there is not a need to document again. Why do you do a full head to toe assessment again on the little babies if there is no change, especially feeders/growers.

I think the most important thing is to always document the assessment anytime there is a chnage in status.

[umcRN, BSN, RN]

Thanks for the replies!

I don't know why we chart full assessments q 3-4 hrs, but this is the only unit ive ever worked in so it's all I know, therefore going to other units where this isnt the practice makes me feel like i'm forgetting to do something. I could totally agree with charting by exception, so charting on things that change or pertinent issues with the specific patient, it just seems strange to me to chart q4 hr neuro checks on a pt with no neuro issues at all or sedation etc.

I will soon be relocating to the peds cardiac ICU so i'll be learning a whole new set of ways to do things anyways I guess!

[littleneoRN]

PICU and NICU here. We chart full or partial assessments as frequently as needed per patients needs, but AT LEAST q4h. Somehow your charting should indicate every time you assess and what you saw or at least what was different if charting by exception. If the patient doesxnt warrant a full assessment at least q4 they don't seem like ICU pts. Most of my true ICU patients have respiratory, pain, vitals (at least per monitor ands hands off) and LOC hourly. CV, skin, and neuro q2h. GU/GI q4h. Hope tthat helps!