Hourly charting

[russianbear]

We are expected to chart something at least once per hour. Obviously changes of conditions, medications administration, etc. but what about those soft threes and fours who are just chilling and watching tv, or those patients when you're just waiting for a bed, etc? What do you chart when really nothing notable is happening?

[JadedCPN, BSN, RN]

Our electronic charting system has an option under the assessment flow sheet for a shortened A-B-C type of assessment where you can click that is was within normal limits or no changes from the last charted assessment. Others choose to type out a quick note in the comment section of the assessment flow sheet saying "Patient stable, watching TV, no changes or needs."

[Emergent, RN]

"Pt resting comfortably"

[russianbear]

"Pt resting comfortably"

I've been criticized for using that exact phrase.

[Nalon1 RN/EMT-P, BSN, RN]

Our charting has an "awaiting" section we can click, lots of pre-listed options (lab results, radiology results, dispo, transport, ride, admit orders, bed assignemnt etc, as well as a free text "other").

"Pt resting comfortably" is a subjective statement since it is your opinion they are comfortable; try something like "pt resting in room/bed with no complaints", that can be verified since they have not complained (but everyone complains, I know).

[amzyRN]

our monitors that records vital signs go into the EMR automatically so we can just save the data. I try save vitals every hour on an ESI 3, ESI 2 more frequently. Sometimes I do more often. Ive been trying to chart my observations every hour to document that I have laid eyes on the patient, but honestly if I'm doing something emergent the charting on the stable patients go by the wayside a bit. There are seminars on charting that I would like to take so that I chart what is needed to protect my license. I don't believe in extraneous documentation because I do think it is a waste of time that can be used other things more important. I still see some people chart "will continue to monitor" which is a waste because that it totally meaningless and will not do any good if called in for a deposition.

[foggnm]

"No change from initial assessment" or "No change except..."

[Nurse Beth, MSN]

The frequency of charting assessments or re-assessments is usually determined by facility policy, so be sure and check your policy. Outside regulators (CMS & JC) do not require hourly notations.

[nurse2033, MSN, RN]

patient chilling watching Greys Anatomy

[djh123]

I don't know what you mean by 'soft threes and fours', but ... having to chart something at least every hour? Sometimes I don't chart *anything* until I've been there 8 hours. Reading stuff on this forum makes me realize sometimes that although my workplace (and the company) are screwed up, there are always even MORE stupid things someone has thought up.

[BSN16]

My facility requires i chart interventions i did for the patient q2...which is actually really stupid because it's things like Telemetry monitoring maintained, SCDs maintained....etc

[Guest374845]

I don't know what you mean by 'soft threes and fours', but ... having to chart something at least every hour? Sometimes I don't chart *anything* until I've been there 8 hours. Reading stuff on this forum makes me realize sometimes that although my workplace (and the company) are screwed up, there are always even MORE stupid things someone has thought up.

If you don't know what the OP means by "soft 3 or 4" ESI patients, then it doesn't surprise me you wouldn't understand hourly/q2h ER charting. It's pretty standard in medium-to-large EDs in the US.

My facility likes q2h charting, so I usually throw in something like "vitals stable on room air/O2" and/or status of a test e.g. "returned from CT, tolerated well, no new complaints".