"will continue to monitor" - page 2

Say you are writing a general head to toe assessment in the nurses' notes. Nothing is really going on with the patient. (It's a physical therapy rehab unit). If you write "will continue to monitor"... Read More

  1. by   Mommy_of_3_in_AL..RN
    Because i am an ICU nurse, our charting rules are a little different. We have a 5 page flowsheet to document everything every twohours, in addition to one hour vitals. We also have a blank sheet for our narrative assesment. This is how i do it...
    Initial shift assesment is documented on he flowsheet, then i write out the assesment on the narrative. I also address anything there that is not on the generic flowsheet, like any drips that are running, if there is any famly at bedside, etc. I follow the flowsheet to document the assesment every two hours, and chart in the narative when the physician comes in, any PRN meds given, the reason and outcome for said PRN meds, an any change in the patient status. If the patient remains unchanged, i make sure to note inthe assesment that "there are no changes from previous assesment. will continue to monitor" because although this is a generic entry, it shows that i have assesed the patient and noted no changes. I do this midshift and at the end ofthe shift. I have been told that i chart too detailed, but isnt detail better than not?? If my chart ends up on a lawyers desk, i would rather them have three pages of correct assesment data to sort through, instead of a couple lines that only say "no change noted"..right?
  2. by   MikeyBSN
    Quote from Mommy_of_3_in_AL..RN
    Because i am an ICU nurse, our charting rules are a little different. We have a 5 page flowsheet to document everything every twohours, in addition to one hour vitals. We also have a blank sheet for our narrative assesment. This is how i do it...
    Initial shift assesment is documented on he flowsheet, then i write out the assesment on the narrative. I also address anything there that is not on the generic flowsheet, like any drips that are running, if there is any famly at bedside, etc. I follow the flowsheet to document the assesment every two hours, and chart in the narative when the physician comes in, any PRN meds given, the reason and outcome for said PRN meds, an any change in the patient status. If the patient remains unchanged, i make sure to note inthe assesment that "there are no changes from previous assesment. will continue to monitor" because although this is a generic entry, it shows that i have assesed the patient and noted no changes. I do this midshift and at the end ofthe shift. I have been told that i chart too detailed, but isnt detail better than not?? If my chart ends up on a lawyers desk, i would rather them have three pages of correct assesment data to sort through, instead of a couple lines that only say "no change noted"..right?
    We start ICU flow sheets in the ED when we are holding the patient. In general, most people like them. I'm a little attached to my own personal method of charting, so I'm a little resistant to the ICU flow sheet. However, I admit they are well-organized and useful when the patient has a multitude of issues. Perhaps I just need to get more comfortable with them.
  3. by   MikeyBSN
    Quote from mustlovepoodles
    This is excellent charting. As a peds nurse, I often notice that parents perception of a child's illness does not reflect the reality of a child's illness. Accurate charting can save your butt. Mommy may be telling everyone that Jimmy is "lethargic and can't keep anything down", while you see that Jimmy is sitting up in bed playing with legos, interacting with staff, and sipping on a little Gatorade. I chart exactly what the parents tells me("mother reports that child is lethargic, not keeping anything down. RN notes that child is smiling, playing with legos, sipping on 30cc Gatorade, no vomiting, T98.6.) I never chart anything as nebulous as "will continue to monitor." If I don't come back to report an update, it just leaves my charting up for examination.
    I must admit, I've seen what I think is some shoddy documentation when it comes to peds. Not that I've never made mistakes on documentation, but I think some nurses who don't work peds much don't chart well. For example, I love it when I read that the newborn is awake, alert and oriented X 3. Whatever that means. How exactly does one determine that, the Vulcan mind meld?
  4. by   cherrybreeze
    No LESS than every two hours? In what type of unit?? I work on a med/surg floor, and the nurses' notes differ from the assessment charting (obviously). We chart by exception, with a minimum of one note in 24 hours. I cannot imagine charting something on a stable patient every 2 hours. There just isn't anything to SAY.

    I do use "will continue to monitor," but it will follow a specific note, like regarding pain or respiratory status. And I will follow up that statement later on with what was observed.
  5. by   McBx3
    Quote from MikeyBSN
    I must admit, I've seen what I think is some shoddy documentation when it comes to peds. Not that I've never made mistakes on documentation, but I think some nurses who don't work peds much don't chart well. For example, I love it when I read that the newborn is awake, alert and oriented X 3. Whatever that means. How exactly does one determine that, the Vulcan mind meld?
    Haha, this is great LOL Stupid question, but I've never worked in nursery/peds, so what kind of thing would you document for a newborn?
  6. by   mama_d
    I'll use "will continue to monitor" when dealing with an issue such as BP out of whack, temps, etc. It's my little key phrase that indicates that should, for some reason, my charting end up getting investigated to point to the appropriate section for follow up. Such as "BP of 190/100 noted, hydralazine IVP PRN administered, will con't to monitor" and then frequent BPs in the graphic. Once to my liking, I'll chart "BP stabilized, will con't to monitor per previous orders" or something like that.

    I do use a lot of fluff in my narrative, but only b/c our flowsheets are so thorough. It does make me crazy when I'm trying to find info on our med-surg flowsheets though, they are much less thorough and our med-surg nurses only chart q 12 and do not do narratives in general, even when something is going wonky with the patient.
  7. by   diane227
    Never write continue to monitor unless you can demonstrate that you did that, either with a written note or by using a flow sheet of some sort. Always try to make an end of shift entry and be specific.
  8. by   Mommy_of_3_in_AL..RN
    OK let me clarify..in out ICU, we document on the generic flowsheet every two hours..its has little boxes where you write intake/output, vitals, neuro status, pulses, and document the patients sedation status if they are sedated..things like that. We do not have to write a narrative every 2 hours. I only use will continue to monitor if there is something wrong, like the previous poster said...if i give a PRN for fever, i will write what i gave, the route i gave it, what the temerature was before i gave it, etc, then follow with will continue to monitor. I will then go back in an hour, two, or however long i feel necessary for the patient, recheck the temp, record that, and continue for that. I do that will all PRN meds, as well as things potassium bolus if the Potassium is low, or whatever. I ALWAYS go back and write something demonstating that i did reevaluate the patient after using that phrase.
  9. by   mustlovepoodles
    Quote from McBx3
    Haha, this is great LOL Stupid question, but I've never worked in nursery/peds, so what kind of thing would you document for a newborn?
    How he's nursing, whether he is waking easily for feedings, if he's nursing hungrily. Document the quality of muscle tone, crying. How many times they urinate, what color and consistency the stools are. Newborns sleep a lot the first 3 days(that is, unless it's my son,Attila the Hun) so you wouldn't see much interaction with parents and staff, necessarily. they can't really focus their eyes well, smile, or be very active. But you can take note of the activities they do have: "Skin pink, flexes arms and legs, cries vigorously during diaper change, taking bottle with earnest sucking, nursing every 1 hour, latching on appropriately, meconium stools." that sort of thing.
  10. by   marmsgirl
    i will admit i use will cont to monitor but not at end of shift rather during noc while pt sleeping. I give brief note about pt condition at midnight when change notes to next day. if patient still sleeping 2 hours later there is no change i will put something like no changes will monitor.. i do chart at least every 2 hr but if there is no change and pt still snoring away what do you write?
  11. by   McBx3
    Quote from mustlovepoodles
    How he's nursing, whether he is waking easily for feedings, if he's nursing hungrily. Document the quality of muscle tone, crying. How many times they urinate, what color and consistency the stools are. Newborns sleep a lot the first 3 days(that is, unless it's my son,Attila the Hun) so you wouldn't see much interaction with parents and staff, necessarily. they can't really focus their eyes well, smile, or be very active. But you can take note of the activities they do have: "Skin pink, flexes arms and legs, cries vigorously during diaper change, taking bottle with earnest sucking, nursing every 1 hour, latching on appropriately, meconium stools." that sort of thing.
    Thanks This helps alot!
  12. by   RobLPN
    I don't use "will monitor" because then you must prove with more documentation you did.
  13. by   RobLPN
    I also don't use "No change" because if something happens how can you prove no changes unless you assess the pt . For examople, can there be no changes to lung sounds without listening again to say no change.

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