documentation in the NICU

SteveNNP, MSN, NP · Feb 20, 2007

Maybe you can purchase an adult charting tool and adapt it for neonates. We use flowsheet/exception charting where I work, but I'm a nerd and write several narratives throughout the shift, including fleshing out my assessments. Here's a breakdown of what I document:

Neuro- activity, pain score, motor activity, fontanelles

EENT- chart abnormals only

Resp- ETT size, placement, vent type, settings, chest wiggle, BBS.

Cardiac- murmurs, rhythm, general perfusion, color.

GI- OG/NG tube depth/placement, aspirate descrip., BS, abdomen/girth,

GU- voiding, urinary caths, etc

Skin- temp, color, integrity.

Lines- PIV's, UAC/UVC's, PICCs, A-lines (including waveforms and peripheral NV checks)

- I then end with a general intervention note, such as "infant turned/repos", etc...

I try to write something q2-3 hours such as interventions, quick assessment, etc. I write a final note at the end of my shift with line/tube rechecks, general infant condition, etc

I hope this helps somewhat....

Stephen

RainDreamer, BSN, RN · Feb 21, 2007

We only chart by exception and use the flowsheets to document everything.

I was always taught not to double chart. Everything is listed in the flowsheets, and I don't make extra notes about what's on the flowsheet unless it's out of the ordinary, I don't have enough room to make a small comment in that block (we do all computer charting), or if I had to notify the MD about something.

Do you use flowsheets where you're at? It sure makes life a lot easier!

pasofino · Mar 24, 2007

Stephen:

Just getting around to replying since I am new to this site. I want to thank you for the info. I am struggling through the NICU internship program but think I will make it. I am overwhelmed by the amount of information to retain. Appropriate charting and rapid medication calculations seems to be the biggest hurdle.

SteveNNP, MSN, NP · Mar 25, 2007

Flowsheets are great when they cover all the bases. I personally wouldn't want to end up in court having to defend a check mark I placed in a box on my flowsheet.

RainDreamer, BSN, RN · Mar 25, 2007

I guess different flowsheets are different. On our flowsheets, there's not just "checkmarks" and they do cover all the bases. They go into more detail than just "check". And like I said you can make extra comments on the actual flowsheet, in each box (all computerized) if needed.

justjenny · Apr 4, 2007

Our documentation includes extensive flowsheets. We are supposed to chart based on "problems" identified at admission (resp, tissue, pain, etc.) but I have adapted to my own style to be sure that I cover all of the bases.

We have a spot for all Vitals, then a flowsheet, then documenting I&Os and then for a narrative that basically has described the infants general status, family visits and any/all tests, etc. performed that day.

HTH

Jenny

Imafloat, BSN, RN · Apr 5, 2007

We don't check boxes either. Our chart has codes on the bottom and each section is numbered. Skin might be box #1, on the bottom of the chart it says #1 W-warm, D-dry, I-Intact, Ab-abraded, etc. At the end of each assessment section there is a space to write anything different. Perineum might be box 12, if a baby has a rash I put R, Ab for red and abraded. In the space at the end of the skin section I will write 'Triple paste applied to peri area.' We also have a narrative on the back of our chart.

randybayrn · Apr 13, 2007

We are all computerized. In the morning most chart on the flow sheet by system covering all systems. Then I was taught to just chart by exception each 3-4 hours after that depending on the babies care times. So each time I chart after the initial head to toe, I chart position changes, feedings, things like this that are done at each care. Our MAR keeps track of each med given and pain and IV's pop up automatically to be charted on every 2 hours. We also chart on safety/emergency once a shift and things like serocult test and blood sugars when necessary.

justjenny · Apr 13, 2007

We are all computerized. .

What system/program do you use? We will soon be going to an all computerized form of documentation...I am wondering if it is more work, or if it is easier (once you get the hang of it)

Jenny

RainDreamer, BSN, RN · Apr 14, 2007

I've only ever had experience with computer charting, that's what they were using when I first started in the NICU a year ago. Personally I love it and can't imagine having to write everything out. Of coursue it took a little while to get the hang of it, but once you do it goes really fast.

But like Randy, we have computerized flowsheets that are detailed, by each system. We have our vitals along with our assessment on one page (vitals, resp, cardiac, skin, GI, GU, etc). Then the neuro page. A page for I&O. A daily care page which includes positioning, comfort measures, parental contact/teaching, safety checks, type of feeding (how well they nippled and/or how many minutes the gavage feed was run over). A page for safety checking all of our equipment and also to keep track of any procedures done and/or labs. Then site care which includes hourly assessment of IV sites.

It's all in flowsheet format, but it's more than just a "check". You have many options for each box and you can also add additional quick comments in each box without having to write a note.