what's most effective documtatio n

[kygydy]

I would like to know how flow sheet charting affects the care plan if there is little room for writing. We have a flow sheet which has some measure of coding for disruptions e.g. s for swollen iv site but not everything is so well detailed and there is the tendency to for get when the block writting is used. Do I encourage nurses to do a full assessment at the start and close of each shift. A little impractical, so what are your thoughts

[NicuGal, MSN, RN]

Not quite sure what you are asking. Your unit should have a routine care protocol to follow. We do a full assessment with hands on care, but we use EHR/EPIC for charting. You should chart to the exception.

When we long hand charted we did a full written assessment by system. IVs are still assessed hourly.

Not sure how you want to tie care plans in. For both ways we always chart separately for each problem, usually once per tour of duty.