Documentation in the ICU

[*LadyNurse*]

How often to you document assessments in your ICU? What is your charting like?

At my facility we chart full head to toe assessments every four hours, vitals qhour, etc.

Sometimes it is more often depending on the status of the patient.

Some nurses in my unit have tossed around the idea of doing a full head to toe with your first assessment and then making a note to chart changes for your other assessments.

I am just wondering how different facilities chart in their ICUs.

Thanks.

[meandragonbrett]

Full head to toe qshift and then we only chart changes the rest of the 12 hours.

[duhitsbrielle]

The ICU floor I was on in school did an initial head to toe and then charted assessments every 2 hours. Mostly copying and pasting the initial assessment over and just changing anything that had changed. The vitals automatically charted every hour from the machines.

[eatmysoxRN, ASN, RN]

Full head to toe every shift. Flowsheets every 2 hours that include pretty much a full assessment including vent settings, breath sounds, NGT documentation, positioning, Foley/urine, bowel sounds, neuro checks, pulses, current tele. Even the bed type.

It's extremely repetitive. We are also required to make a note every shift that is diagnosis related. (this is both MICU & SICU).

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

[murphyle, BSN, RN]

Head-to-toe assessment, LDA (Line/Drain/Airway) documentation, SIRS screen, Braden and safety assessment are all done q shift, plus any changes. Strips (at a minimum two ECG leads and your alarm limits, as well as anything else with a waveform - art line, PA line, et al) have to be printed, mounted, analyzed and signed q shift. Diagnosis-related notes also have to be written q shift. Neuro and neurovascular are done q4h unless ordered otherwise. VS, I&O, vent settings, positioning and glucose check q1h unless ordered otherwise. (By policy you can go to q2h on your glucoses if your patient has had target-range glucoses and no titration required on their insulin for four hours or more.) If your patient is in soft wrist cuffs for a vent, that has to be checked q1h; leathers are vanishingly rare here, but if your patient does have them it's q15min.

On fresh post-ops, we do initial head-to-toe within 15 minutes of arrival, and VS and I&O q15min x4 sets, then q30min x4 sets, then q1h thereafter. Hemodynamic profiling off the Swan is done on arrival, then q2h and PRN.

[hodgieRN]

If you want to know the right answer, look at your policies and procedures for your facility. The P&P is the end-all and be-all. They can be slight different from one hospital to the next. There should be a critical care section that specifically details the standards for proper documentation at your facility. If you are doing anything other than what the P&P states, then the charting is substandard.

I don't know if you have ever been called to testify in court. Everyone knows that your charting should be in order, but a lawyer can go after you for not charting the way your policy states. Its what they do to discredit you.

If you chart a full head to toe in the beginning and then just chart any changes, its only OK if your P&P states that it is. You'd be surprised how many people don't chart according to the P&P. At my hospital, we have to do a full assessment every 4 hrs, and a focused assessment every 2. We are not allowed to click "no changes" for the rest of shift (after the 0800 assessment). No changes can only be done in-between the full or focused assessments (like if I was doing 15 minutes checks on something). But that is specifically listed as a policy.