Flow Sheet

I can only give you information from my PICU, and I'm guessing that our flowsheets are much more complicated than you need for your patients. My advice would be to create your own flowsheet in collaboration with some other nurses. Then submit it to your management for approval and printing.

In short, here is what our flowsheet contains. We use one flowsheet per patient per 24 hours. So a new flowsheet begins at 7am. (It'll list the vertical categories as they appear on our flowsheet from left to right:

Time, vital signs, ventilator settings, blood gas results, electrolytes, blood glucose, intake (several columns for multiple IV fluids/meds and a section for po intake), output (urine, emesis, stool, chest tubes, other drains), and a comments section to add notes/important occurances. (Line removal, one time doses or PRN meds, anything reported to the MD, etc.) There are 24 horizontal rows on the flowsheet- one for each hour of the day.

The rest of the flow sheet is the assessment. It has six vertical columns of identical assessment forms in a check-off format. So after your assessment, you check the boxes that match your assessment. We do assessments every four hours. But on adult floors where I have worked, it was every 8 hours or every 12, depending on the policy.

If a patient doesn't need vitals every hour, we just leave the vitals blank for that hour, and fill in the I&O or anything else that needs to be recorded.

Assessments are charted (at minimum) Q4H on my floor and any changes PRN.