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Discussion

Close & intensive observation sheet behaviors/actions

Would anyone be willing to share what their facility uses for patient behaviors/actions on close or 1:1 observation sheets? The inpatient unit I work on is considering adding to our current list. At the moment we use: situationally appropriate, inappropriate, depressed, anxious, restless, hostile, hallucinating, isolative, attention-seeking, resistant, and confused. Thank you in advance.

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    We keep the codes simple: just the patient's location and whether they are sleeping and awake. If we need to provide specifics, there is a space next to each entry so we can write a narrative if needed (e.g., "Appears to be responding to internal stimuli AEB...")

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    We don't even check asleep anymore. We check quiet. Lawyers don't want a dead patient from something like heart attack being charted asleep for 6 hours.

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    • Expert
    We don't even check asleep anymore. We check quiet. Lawyers don't want a dead patient from something like heart attack being charted asleep for 6 hours.

    I agree, except our forms don't offer me the "quiet" choice.

    I do write in my narrative that patient is resting in bed quietly with eyes closed and regular, unlabored breathing.

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    The facility that I used to work at required the direct care staff to document each resident location and what they were doing every 15 minutes, whether awake or sleep. When on one to one, of course someone was there constantly within arms reach of the patient.

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