Hourly charting

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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?

Specializes in ED.

We use software that is template based and we can request for certain templates to be added as we see the need. We have added several "rounding" type templates that we can just drop in every hour or so but we are "required" to chart something at least every 2 hours. Our software also prompts us with 1 hour medication reassessments so it is pretty easy to get some type of charting done every hour.

My favorite template to use is the "Rounds made" template that has several options for what type of comfort measures you performed...watching TV, blanket provided, lights dimmed, offered pillow, etc.

When I don't use a template or I need something different I use...

"Pt resting on stretcher with eyes closed; easily aroused by verbal stimuli. NAD distress noted at this time. Pt encouraged to report any needs or changes to staff. Will continue to monitor patient for any further needs or changes in status."

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