Documentation in ICU

[OnlybyHisgraceRN, ASN, RN]

I have a rather stupid question for my ICU nurses but what exactly do you write nursing notes on?

We use VAR charting and I do that well, but when there is not a variance I don't know exactly what I should be charting on my nursing note.

My question is: What do you chart when there is no change in condition, and you are required to write a VAR note.

My second questions is do you chart every time there is a change in medication, consult, or any other new orders that are routine?

I guess I basically want to know what to chart and what not to chart?

[ckh23, BSN, RN]

I usually just write something along the lines of "Pt sleeping, easily arouses to verbal stimuli, no changes from previous assessment" At another facility I worked at we boxes for every hour and a check mark meant no changes and a star meant some type of change that was then elaborated on in the nursing notes.

I do not charge changes in meds or orders. When the docs put orders in, they print out and we sign off of them and it becomes part of the chart. The only other times I chart is if tube feeds are started for the first time, or prn med needs to be given and the response, if a certain drip is started, etc.

[OnlybyHisgraceRN, ASN, RN]

This helps alot. Thank you! Sometimes its' the simply things that throw me off a bit. Some of my preceptors like for me to double chart.

[dirtyhippiegirl, BSN, RN]

This helps alot. Thank you! Sometimes its' the simply things that throw me off a bit. Some of my preceptors like for me to double chart.

This drives me nuts! We use a system that's entirely electronic -- MAR, assessments, orders, consults, everything is done electronically. You can also write nursing narrative notes and my main preceptor was always adamant that I write my entire head to toe assessment in a narrative note, as well. But that's double charting! Argghhh.

I do narrative chart every time I have to call a doc -- either for a medication, or a change in the pt's status. I also chart verbatim what the doc orders if he's having me put in the orders into the system. Technically, this is double charting but we have at least one doc in particular who likes to have us put in orders and then will back track and be like "oh I didn't say to put THAT in." Otherwise I just chart "orders received."

[umcRN, BSN, RN]

We double chart a lot in my unit, they are all for CYA.

Aside from hourly vitals, drips, I&O's, lines/tubes/drains (have to be documented hourly as well) and q4 assessments we also have to write the longest progress notes.

We start with the "overview". This is an easy to access document where we write the date and an overview of our shift. For example yesterday I wrote on my pt: No vent weans, to fluro for upper gi - multiple PRN's for trip/procedure, mom discussed g-tube with doctor.

There is a "blurb" like this for every day the patient is in the ICU with big events (codes, surgeries, procedures) in bold for easy access to those dates. When the document is open we can see everything that has happened to that patient since admission.

Then we write DAR notes on every patient problem which is a huge pain, especially if you have the kid for three shifts in a row and make essentially no changes on one or more of the problems then you are essentially writing the same note over and over. In the peds CICU i work on just about every patient has a minumum of four problems to chart on (cardiac, respiratory, nutrition, and parental knowledge) then add other problems like skin, infection, thermoregulation...it gets out of control

[blucrna]

My hospital uses EPIC computer charting so the days of long narratives are just about over. Like prior posts we can chart progress notes in the notewriter for cya purposes. I don't do assessments unless an event happens like the time leading up to an RRT. Double charting is for the birds

[lesdrn]

Have you ever gone to a deposition? I have and my charting saved my a**! Now we have electronic charting and I do chart a little differently than I did on paper, but I do hit the high lights of my assessments. I chart in narrative my lung sounds, my cardiac rhythm and anything that is abnormal at every assessment. This may be something that is in my assessment that is charted every 4 hours, but if I have to sit at a deposition, I want to read my narratives to read what was wrong with the patient and try to jog my memory. In nursing school, I was taught to chart by exception, so if I didn't address it in my note, it was normal. I still believe in that principal. BUT, if you go to a deposition, the plaintiffs attorney will ask you what your charting practice is, and do you ALWAYS chart the same way. So, I guess the moral of the story is, chart to protect yourself, chart defensively. There are classes that you can take to teach you how to do this.

[eCCU]

EPIC is the best so far i have seen:-)

[ktliz]

They gave us a handout in orientation on when to write narrative notes. Along with the following list, it also refers you to your organizational policy.Admission/transferTransport off or back to unitChange in level of carePost procedure- what was performed, who performed it, how did patient tolerate itChange in patient condition, behavior, signs & symptomsPt response to clinical interventionsSignificant events: fall, rrt, code blue, restraintsCommunication with other members of the healthcare team: document conversation occurred and what was said, include orders received and interventions implementedCommunication with pt/family, include quotes when relevantNursing participation in family conferences, who attended, what was discussed, did pt/family verbalized understanding of planDischarge: pt condition at time of discharge, who accompanied pt, education provided and pt or family verbalized understandingWe are required to write a note q4 hours with our assessment... If none of the above apply, I just write "assessment as noted in Metavision".Our hospital is looking into Epic to replace the 3 or 4 different systems we currently use across the network. The comments on here are getting me excited to for it!

[ktliz]

Whoops, sorry for the huge block of text! The iPad does funky things sometimes.

[nrsang97, BSN, RN]

EPIC is the best so far i have seen:-)

We are going to EPIC next year. It will be so nice not to have 2 or 3 systems to look up labs, and narrative chart, + paper chart.

[smarine123]

You chart as much as it takes to make you comfortable. Charting has also saved my butt. There was a suite against every nurse, Dr, and the hospital on a patient and I was the only one who was not liable solely due to my charting alone. I was told that by an attorney! So, chart defensively!!!! I teach this to all new nurses. You make sure that you document as though you were going to be sitting in court with this patient. What do you think you should chart? If you do this, you will document just the right amount. Statutes are usually about 7 years. Will you remember everything that has gone on 7 years ago? If you didn't chart it, you didn't do it. So, be careful. NO ONE will be standing behind you backing you up! You will be alone! So, be careful. Those who are wanting you to do a narrative are simply trying to keep you out of court.