Nursing Documentation in ICU

  1. Hi-

    I work at a community hospital with a 13 bed ICU. Currently, the nurses in ICU document a shift assessment q2h; this is a complete head to toe assessment. Is this similar to charting in other ICU's?


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    About trixie

    Joined: Nov '01; Posts: 48; Likes: 54


  3. by   Biffbradford
    Busy CVICU (post open heart) - head to toe Q4hrs, add nursing notes in between. If the patient is so sick that they need Q2hr assessments, then you don't have time to type!
  4. by   KJStarling
    We do a complete head to toe Q4H and a focused assesment Q2H. That is we document on the main issues for the focused assesment. And only if something has changed, because we have the option of saying "no changes to previous assesment" if it is the same nurse and same shift.
    Good Luck.
  5. by   NickiLaughs
    We do charting by exception. We chart the detailed assessment at the beginning of shift, and only change things that change during shift. I love my electronic charting system, I feel like I'm able to focus ont he patient more, plus we just have to double click for vital signs to enter. So instead of spending all this time charting vitals, i can focus on what I need to do about those vitals.
  6. by   TEXAS ICU RN
    We chart Head to Toe Q4, Chart changes when they happen, Rounding assessment Q2. VS @ 15, then Q 30, Then Q1 hour. Some hospitals have the new systems that allow VS documentation by the click of a button that are slaved over from the monitors, depending on pt needs, to be done as often as needed.
  7. by   StayLost
    Q4 here
  8. by   turnforthenurse
    We do complete assessments Q4 and focused Q1H.
  9. by   ChicagoICUNurse
    Neuro ICU. Head to toe assessment Q4 and neuro assessment Q1.
  10. by   Ruby Vee
    every four hours here -- and in every other icu in which i've ever worked over the past thirty years or so.
  11. by   Penelope_Pitstop
    I'm not in the ICU, but our MICU documents head-to-toe every 2 hours, stepdown floors do every 4.
  12. by   umcRN
    Three ICU's in my hospital and three documentation ways:
    NeonatalICU - Full assessments q3-4 depending on the kids "care" schedule
    PedsCardiacICU - Full head to toe once, then neuro/resp/CV q4
    PICU - Full head to toe once, neuro q4 and other changes q4
  13. by   CCRNDiva
    Q2h head to toe assessment, hourly neuro checks if needed. VS q1-2h

    **We have a hybrid of electronic/paper charting and I swear that I spend more than 50% of my time charting. I feel like this electronic charting makes my work life he**. Charting was much faster when it was all paper. (I've heard from others that this is due to the incomplete system our organization purchased though.)