How often do you document...

[NeosynephRN]

OK. Tell me how often do you document things like GCS, and peripherial pulses...now I am not talking about a neuro patient or like a fem pop...just a good ol regular MICU patient. We were going through some policies and one says we should be documenting GCS on every patient every hour...I feel that is excessive. I mean if I have a stroke or acute neuro issue, of course, but what about my AMI or my GI bleed...I mean I may be assessing this with nearly every interaction I have, but I do not officially document it. I have been looking through my AACN book and have not found recomedations on this...what is your policy and protocol??

[meandragonbrett]

We document a full head to toe physical assessment q2h. We then have "extra" flowsheets we add in and document on the other hour based on their problems. We chart vent assessment q1h, neuro q1h if they're a head patient, etc.

i.e.

1900--Full physical assessment, care plans, patient/family education, multidisciplinary plan of care, etc.

2000--Vent assessment, restraints, falls interventions, etc.

2100--Full assessment

2200--Vent assessment, restraints, falls, etc.

We also chart q1h vitals and I/O.

[mcleanl]

Q4h for the average run of the mill patient.....of course (as you suggested) the policies change with different diagnosis/surgeries and medical interventions.

Q1h seems excessive to me for GCS unless the patient is admitted with neuro issues. I have to be honest...I even think Q2h head to toe documented assessments are a bit much. I do document Q2h and PRN but not a complete and full assessment.

[ICUNurseCline]

We are on q4 hours. If you are concerned about one particular assessment finding, it's cover-your-butt and document to the hilt. We do VS q 1 hour or q 15 for any drip. If I feel unsure I automatically do VS q 15min just to be safe. If I were you, I'd consider asking your manager about forming a policy for more standardized documentation.

[NeosynephRN]

We do q4 head to toe. VS are dependant on status...any drips q15, at the max q1hr if they are on no drips and stable. We do q1 rounds and q2 IV site rounds. I just think specifically on the GCS and the pulses we have been documenting with the q4 head to toe and that seems fine, unless otherwise warented by pt condition! Thanks for the input...

[cardiacRN2006, ADN, RN]

We document a full head to toe physical assessment q2h. We then have "extra" flowsheets we add in and document on the other hour based on their problems. We chart vent assessment q1h, neuro q1h if they're a head patient, etc.

i.e.

1900--Full physical assessment, care plans, patient/family education, multidisciplinary plan of care, etc.

2000--Vent assessment, restraints, falls interventions, etc.

2100--Full assessment

2200--Vent assessment, restraints, falls, etc.

We also chart q1h vitals and I/O.

Same here.

Q2 hr assessments

Q1 vs/ IOs

Q15 min vs when titrating or giving blood.

[DaretoDreamRN]

Q4hrs....

Q2hrs seems overkill for me..but hey..u learn everyday

Q1 if it was a neuro patient or depending on the circumstances

q15 mins when titrating drips

[mcleanl]

you guys that are doing q15min vs when titrating drips.....do you have computer or manual documentation of vs?

[cardiacRN2006, ADN, RN]

you guys that are doing q15min vs when titrating drips.....do you have computer or manual documentation of vs?

I can go back and print them off my monitor, but we paper chart so I still have to write them down on the flowsheet.

[NeosynephRN]

We document them by hand...can print them and document...thank goodness when you get up to 4 pressors....

[chani]

As a general rule vital signs q1h for stable ICU patients and q2h for non-intubated patients. Vital signs are HR, BP, RR, O2 Sats and pain

When titrating meds - 1/4 hrly when changing (any more frequent is not useful) and you can go back and look at what its been.

Ventilator obs hrly

Head to toe assessment once per shift

chest Auscultation 2qh for ventilated or respiratory patients

Neuro patients GCS hrly when stable, more often if not.

GCS is only appropriate for neuro patients who are not receiving meds that might alter the level.

Non-neuro patients require an appropriate sedation +/- agitation or delirium assessment - hrly to 4hrly

BSL 1-4qh depending on diagnosis, insulin infusion and stability

Urinalsys - daily unless indicated by diagnosis or treatment

Fluid balance hrly

All manual as no computer system.

Really important to get it right if you are using a patient outcome database like APACHE or SAPS because if you dont get the correct vitals documented the patients scores will be wrong, they wont score as appropriate and this will have an effect on your units outcome stats