Documentation standards

[PedsERRN]

We are having a serious problem with lack of documentation on our unit. I believe that anyone should be able to pick up a chart and know exactly what is happening with a patient. Not so in our ER! Most of the nurses feel that they don't have time to properly document, but I'm also finding they don't know what to document. I'm trying to come up with a documentation tip sheet for the nurses because I worry about their liability if something should happen to one of their patients after they relinquished care to someone else.

I looked on the ENA website but can't find anything about standards. Can anyone share with me time frames for documentation? For example, VS q4h, assess q2h, assess within x amount of time after an intervention?

Thanks for the help! :)

[babynurselsa, RN]

This sounds like a disaster waiting to happen.

What kind of paperwork are you currently using? Quicker and easier may be check box type assessments with space for comments. plus a narratice section.

Not documenting because you are too busy is not going to hold up in court.

In every ER I have ever worked we try to do VS no less frequently thatn Q2 some days that is a little pie in the sky for the walkie talkie sort of pt. If they are sick, sick as fx as appropriate. With f/u vs 30min after med admin and DC VS.

As far as what to document keep it complaint focused. If you document they are complaining of it you had better address it.

You might want to look at the T-sheet system. many ER's that I do shifts at are using them and it is a focused sheet for assessment plus documenting interventions.

[Aneroo, LPN]

We have computer charting, so it is a little bit quicker for us. Trauma's are still paper charted.

I record VS on monitored patients at least every hour, more often if they're more acutely ill or getting meds. On the other side where we have the less acute patient (kidney stones, h/a, "didn't make it to the doctor in time" patients), I try and do them at least every two hours.

I try my hardest to chart on my patients at least every two hours also, even if it's just "resting in bed, arouses easily. Resp even and unlabored. Denies CP or SOB. NAD. Call bell in reach."

I had it pounded into my head by clinical instructors that I needed to chart at least every two hours. That way if something happened to my patient, it was documented recently that they were alive and well.

I don't have any tips to help make it easier for your co-workers. To me it is common sense to chart that often. Even with paper charting it doesn't take but two minutes to write that out.

-Andrea

[mommatrauma, RN]

We use the T-chart system but are switching to a computerized system in the fall...we have department policies and standards that govern our documentation minimums. Check your policy book, you should have something there.

[Rena RN 2003, RN]

we do focused assessment with more detail the more acutely ill. VS every 2 hours or more often if needed. VS within 30 min of sending a patient to the floor. we chart q2h for all patients and more often if needed. within the next year or so we will be doing computer charting.

the times i've seen poor charting has been with nurses that are new grads or new to the ER. your unit based educator should be addressing your problems. talk to him/her. find examples of good charting and pass them around. if you don't have standards in place, make some. ex: right ankle pain. assessment guidelines: color, warmth, bruising, edema, pulses, cap refill, pain scale, injury, wt. tolerance, etc. intervention guidelines: elevate extremity, ice applied, xray ordered, tylenol/motrin (work with the docs to get premedication order protocols established). then write it all down.

the facility i work with now is awesome about nursing protocols. we have protocols for damn near every c/o out there. if they aren't used, the docs will come to you or your charge nurse and say "what's up? why isn't anything done? why wasn't the assessment done?" etc.

[Katnip, RN]

We're required to document VS Q4 hrs or more often if acuity is higher, after medications, and just prior to discharge.

Triage assessment by triage or when receiving an ambulance pt. Then the primary nurse documents his/her initial assessment. Normally we chart the focused assessment, but we now have computerized charting and it makes it easy to just click off a full assessment; after it's been done, of course.

Any procedures done; IV starts, blood draw, urine collection, etc.

Pain has to be documented during triage and after medication and during reassessments, even if they are coming in with no pain.

We also are required to chart their status at least Q2 hrs, even if unchanged. And of course more often if something happens, they leave the unit for tests, or the patient says or does something significant.

[CEN35]

Our ER has a q1hr standard, for ER patients. q15 min for critical care pt's, and q 2 hours for thru care.

When charting now days, you need to think like a lawyer. What would they grille you about?

Personally, my biggest thing was the way they chart. Pt to CT; pt back from ct; pt to x ray; labs sent; lab results back; pt at ultra sound; pt to be admitted to the hospital.

Ok let's ee now that someone was charting how the field trip went? How is the pt? All we know from the prior sentances, is that they went and had their tests done, and some results came back. Since they are being admitted, we also assume they are alive at that point.

So back to the original thing, chart like a lawyer thinks. If something happens anybody should be able to look at the chart, and visulaize the patient, and what kind of shape they are in, and what was done about it.

That's my 2 cents...........

[PedsERRN]

Thanks guys, this really helps! :)