Documentation

[DizzyLizzyRN]

Can anyone tell me where I can find the minimum time intervals for documentation on a med-surg floor? The nurse manager is making it mandatory for team leaders to document in the nurses notes (electronic documentation) at least every two hours on each routine med-surg patient (each team has 7-8 patients).

[toadie]

i don't know that there is a minimal time interval for documenting. at my hospital there are policies for each unit stating when a re-assessment must be done, and that is when we chart. i don't think this is a legal issue. i think its just a hospital policy.

[KatieBell]

Sorry never worked med surg. but I'll say each hospital I have been at has different requirements:

One had Vitals every 4 hours, and some sort of note every two hours.

The one I am at now has vitals every two hours- but no documentation requirement...and hence the documentation there is pretty poor.

[nialloh, RN]

In my hospital we chart by exception (all but ICU). If nothing happened, we don't chart, other then an initial note. My shortest note was 3 lines (although I do write small:) ). This pt was a total negative assessment.

[Thunderwolf, MSN, RN]

Can anyone tell me where I can find the minimum time intervals for documentation on a med-surg floor? The nurse manager is making it mandatory for team leaders to document in the nurses notes (electronic documentation) at least every two hours on each routine med-surg patient (each team has 7-8 patients).

Document "objectively" what you see or assess during the documentation. If nothing is happening and negative, you might want to state something like:

"Patient lying in bed. Resps even, easy. Pt denies any current needs. No overt s/s of distress or discomfort noted. Call button in reach."

"Assessment unchanged from 1800 hrs. Call button in reach. Pt watching TV, sitting in chair."

Maybe, something benign like this. It demonstrates that you actually looked at the patient and no needs were present.

[Daytonite, BSN, RN]

My advice would be to find a computer terminal that is away from all the activity at the desk, if that's even possible. It's not the sitting down and charting, it's all the potential interruptions that are going to pull you away from it if people can see you. Hiding while charting helps. If you have terminals in each patient's room (yeah, right!) do it there.

[miphillli]

Does anyone out their use PIE documentation,if you do,what do you think of it?

[SouthernLPN2RN, MSN, RN, APRN, NP]

I use half narrative/half CBE. I always charted at least q2, even if it was nothing other than "Lying in bed on back with eyes closed, respirations even and unlabored". It did take me a while to get my time management down, but I do like to leave at a decent hour, so I charted as I went.