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?

[djh123]

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. /Quote]

Ahh, well, it makes much more sense to chart more often in the ED, but the OP didn't state it was the ED... but as you say, if I'd worked in one, I'd know what those terms meant (soft 3 or 4 - and I don't know what ESI is either. God, I hate acronyms :^).

[dec2007]

Where I work in the ICU we chart vital signs, I & O, pain, RASS score, and drips hourly, but we don't have to chart other assessments hourly. We do, however, have little laminated "trees" we have to sign a leaf on every hour to prove we have checked on our patients hourly. Anyone else have anything like that?

[Workitinurfava, BSN, RN]

Patient said leave me alone and nurse said I will be back in 1 hour, lolz

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

Ahh, well, it makes much more sense to chart more often in the ED, but the OP didn't state it was the ED... but as you say, if I'd worked in one, I'd know what those terms meant (soft 3 or 4 - and I don't know what ESI is either. God, I hate acronyms :^).

Well, this is posted in the Emergency Nursing forum...

ESI is Emergency Severity Index, a way to quickly triage patients. Level 1 is most severe, Level 5 is very minor. Level 4 are usually pretty simple work ups, and some of the Level 3 patients just barely meet the criteria, and are more like a Level 4 severity.

I have no idea where you chart every 8 hours. Must not be in any hospital setting.

I can see 5 patients in 1 room in 8 hours, and having 4 rooms, well, you can see why hourly charting can be important.

Even on the regular floor they have Q4 hr vitals.

[maporcrn1]

Is hourly rounding is a requirement? If so, charting should be simplified. Previous assesment unchanged is an option.

[LessValuableNinja]

I've been criticized for using that exact phrase.

Pt in no apparent distress, respirations equal and unlabored, no significant status changes noted. Pt denies new complaints.

[caffeinatednurse, BSN, RN]

"Resident is resting w/eyes open (or closed). No s/s of distress, discomfort or pain."

[caliotter3]

When I got told I had to chart q 15 minutes for hospice patients, I distinctly thought that I could no longer work for that company.

[NursieNurse14]

We chart Qhour but our system has a drop down menu for hourly rounding and we can check performed. they also count vitals, assessment or any charting we have done as our rounding for that hour

[cjcsoon2bnp, MSN, RN, NP]

I have a few favorites in my charting when I have to write something. Many times I will put something like...

"Patient resting on stretcher with eyes closed, respirations even and unlabored. No signs/symptoms of acute pain or respiratory distress. RN will continue to monitor."

"Patient updated on plan of care by RN, no questions/concerns at this time."

"Patient denies pain currently and reports resolution of nausea/vomiting after ***** administration. MD aware and RN will continue to monitor."

You get the jist, just something that basically says you know the person is still alive in their room and haven't completely abandoned them. I am always a little hesitant of attaching charting requirements to ESI levels because I have seen nurses lower a patient's ESI rating because they don't feel like having to deal with the increased monitoring and charting (Rating a level 3 abdominal pain workup as a level 4 just to avoid the more frequent V/S and more detailed charting).

!Chris

[R5RN, BSN, RN, EMT-P]

We are required to do hourly notes and they even make a list of what we are supposed to note.

-Reassessment of complaint, pain, airway, breathing, circulation, cardiac rhythm (as applicable), disability, safety, update pt on status, and general reassessment stuff. This is in addition to "interventions" such as meds, ice pack, blankets, oral fluids, snack/meal, lights dimmed, curtain closed or remains open.

If I'm writing a "perfect" note, it would go something like:

Resting on stretcher, watching TV with family at bedside, updated on status. Reports an improvement in shortness of breath after neb tx but still remains with weak, nonproductive cough. CAO x4/4, resp even and unlabored, skin pink/dry, remains sinus rhythm in 70s. Fluids at bedside, lights dimmed for comfort, provided with warm blankets, call bell within reach, bed in lowest position.

ETA: Then we add lots of little notes like "to X-ray via stretcher", "ambulated to bathroom without assistance", "called pharmacy for meds", "family asking for update, provider aware", etc.

[amzyRN]

Pt resting with eyes closed, respirations even and unlabored, VSS, call light in reach encouraged to call with needs. We can set our monitor to take BPs as frequently as every minute or so. We have a continuous puls ox with HR and EKG monitoring of 3 leads if required and this data automatically transfers over to the EMR, we just validate it and boom we have vital signs as often as we want. I find myself just having a set of vitals every hour when I'm busy and if my patient doesn't need that, I will make a note like mentioned above.