Documentation of Hourly Rounding

Nurses General Nursing

Published

Specializes in Medical Surgical, ER, CVICU.

For those of you who are doing hourly rounding, how are you documenting your rounds? Do you use a check sheet placed by the door or do you document in computer charting? We are thinking about changing the documentation in my facility from the checklist to the computer documentation. I am curious to know if anyone else documents rounding int he computer, how they do it, and if there are any issues.

Thanks!

Specializes in ER, IICU, PCU, PACU, EMS.

Yes to both.

There are sheets placed outside of the patient's door which are not part of the patient's legal record. However, they are spot checked throughout the day by 'the powers-that-be' to ensure that the nurses are not just initialing them at the end of their shift.

If the sheet is not filled out at spot check, the nurse is written up.

Hourly rounds still have to be logged into the computer because this is part of the patient's chart. If you don't log it, you were never there.

I love how we have all this extra time to perform redundant charting. I really have nothing else to do.....

Specializes in medicine and psychiatry.

The local paper where I am from publishes a 30 years ago today article. Last week it noted that 30 years ago that day that 25 nurses walked out of the local hospital because they were being worked too hard. Sounds like a winner to me.

Specializes in Hospital Education Coordinator.

we keep a form in the room and staff initials and times visits. BTW, this can be any nursing dept staff, including CNA's. When the manager makes rounds he/she also times and initials so people cannot put in bogus times afterwards. All sheets are placed in the chart during chart-check time at night.

Specializes in ICU.

we have a flow sheet with drop down boxes on the computer. it allows for documenting IV sites, turning, skin care, monitor alarms, mouth care, side gates, activity, and a comment box where you can free text if necessary .........it takes all of 2 seconds to do

Specializes in Physical Rehabilitation, med-surg.

we have an hourly rounding sheet that is also not part of the permanent record. The nurses initial on even hours and the techs on odd hours. Everytime you go in a room, you also push your nurse button or tech button.

Hourly rounding and the attempt to answer patient needs before they call is a good idea, but proving you did it just leads to another stupid paper to fill out.

we started rounding about a year ago. we started with the paper on the door. it was never completed even 80% of the time. we recently went to computer rounding and there is more compliance. i do chart audits several times a week. i limit myself to checking those people that are there that day and if i see an issue with their charting i converse with them immediately. the compliance is better but not where we want it to be yet. i still think that if it was used correctly it would cut down staff walking time and increase pt satisfaction.

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