Documentation Tool for A's/B's/D's

[MinehartNICU]

I'm wondering if anyone has a well-organized documentation tool for A's/B's/Desats in the NICU. I'm on a respiratory committee that is trying to improve accuracy of documentation of events, and think it may be helpful to document on paper vs. in the computer chart. Any thoughts? Anyone have a great tool from their unit they'd like to share? Thanks so much!

[NicuGal, MSN, RN]

We had EPIC build a sheet for us in our program. It basically has a space for

Apneic? Y/N

Bradycardia? Y/N

HR

Desaturation? Y/N

PO reading

Then drop down boxes for activity such as asleep, crying, bottle feeding, BFing, ng/og feeding, position , stim required, other.

[adventure_rn, MSN, NP]

I've used an Epic flowsheet like the one described above, as well as paper charting. I prefer Epic, although the benefit of paper charting is that any nurse who sees the event can chart it at the bedside without having to pull open another patients' computer chart.

I honestly think that the accuracy of event charting depends on your monitoring software, specifically that everybody can a) access it and b) knows how to use it. If your monitoring software is available on every computer and people are adequately trained to pull up event strips, it is much easier to know exactly how long an event lasted and whether it was real or artifact. If nobody knows how the software works, or it's a pain to access (i.e. only available at a single computer or difficult to pull up on the monitor itself), people will tend to use more subjective guesswork.

[NICU Guy, BSN, RN]

Like others have said before, our EPIC software has it built in.

Apnea (Y/N)?

Duration of Apnea:

Bradycardia rate:

Desaturation:

Intervention (drop down):

Position (drop down):

Activity (drop down):

Choking?

Drs can pull up a graph of the events in EPIC on the patient chart.

[HyperSaurus, RN, BSN]

McKesson Paragon. We had click boxes. One for Apnea v periodic breathing v shallow, brady y/n, feeding y/n, stim mild vs moderate v none, a fill in box for HR and for sat. That worked out pretty well, as you could do patient inquiry just for the Apnea/Brady tab and see the trends over whatever time period you wanted.