Quote from blondy2061h
"Pt continues to rest comfortably. Assessment unchanged. Report given to oncoming shift."
I don't know about this for charting ,didn't really tell me anything about the pt.
"Continues to rest comfortably" Does that mean the nurse looked in on the pt who was in bed with eyes closed? Or pt is trying really hard not to not have pain. "Assessment unchanged", unchanged from what? "Report given to oncoming shift" Well, isn't that a standard of care,am I going to write that on all my pt's (over and over) If the facility requires this to be charted, wouldn't I write who I gave report to and what it covered with that pt? Treatment, outcomes, ect.
"Will continue to monitor" Monitor for what ,what goal ,outcome was the problem for this shift?
Just some random thoughts ,not to upset anyone! I know charting would have different standards depending on type of pt and facility. I thought the original question was about long term since it stated needed to chart only once a shift.