I work on a cardiac stepdown unit where there seems to be an increasing amount of paperwork that we are expected to keep up with. In this age of nursing shortages and having to "do more with less", we are bogged down with increased documentation. We have a mediocre assessment flowsheet which entails a fair amount of writing in the nurses notes to further explain irregular findings. We also have numerous other sheets that are kept in folders near the patients' rooms: IV assessment flowsheets, care plans
, pain assessment flowsheets, I&O sheets, etc. I am on the clinical policies improvement committee and we are trying to find ways to consolidate this amount of paperwork as well as avoiding double-charting of information. For example, when we D/C or change IV sites, we are expected to document all of this on the IV flowsheet and our nurses notes/flowsheet; when a patient has pain, we are to document this on our pain assessment sheet and on our nurses notes/flowsheet. Do your hospitals/floors have this amount of paperwork to complete? Do you have the same problems of double-charting? If not, please give some suggestions on ways to improve this. I would love to design a better flowsheet and find a way to have the care plans, I&O's, IV & pain assessment sheets become a part of this flowsheet. Maybe some of you have excellent flowsheets like this - I would love to hear from you! Thanks!