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Discussion

Hourly rounding notes

Hello,

Looking for input here.

I know the basics of what to put in a rounding / update note. Things like "bed low, call light in reach," etc. However I would like to make my notes sound more clinically oriented instead of just adding the basic things....things like patient status, education, notes about the plan of care. I guess I'm just having trouble finding a way to format this in a note, and also it sounds so redundant when you are charting it every hour.

What do you all chart for your hourly progress notes? Just a few click boxes, or do you add narrative notes too? What do you include in your narrative notes? If you are holding a patient for a while, what do you chart?

Any pointers would be great!

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    I honestly don't always do this on very stable patients that I know will be dc'd from the ED without issue. I try to dock a set of vitals every hour unless I'm swamped. I will chart more on an unstable patient. there's only so much value you can add with VSS, call light in reach, etc. If your hospital is monitoring your rounds, maybe you can come up with a shortcut (they have this feature in epic)

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    I only write notes on unstable er patients. Everything else is covered in the assessments that we do. Most patients are only there for a few hours.

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    We use a template based system and have added a Rounds made template that will allow us to chose which "comfort measures" we implement: watching TV, lights, dimmed, repositioned in bed, etc.

    I also like to add....."Pt resting comfortably in bed, NAD noted at this time. Pt encouraged to report any needs or changes to staff. Will continue to monitor patient for any changes or needs.

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    "Pt resting quietly with eyes close, no needs identified"

    "Pt denies needs; vss at this time"

    "Medicated for pain per MAR, no additional needs identified"

    Short, sweet, simple...just a note about what I did or what they need.

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