ICU documentation templates??

RhinoRocketRN · Jul 19, 2011

Someone had given me a template, however I did not like it...

This is what I do for my report on a blank piece of paper, i fold it in half

http://desmond.imageshack.us/Himg683/scaled.php?server=683&filename=outlined.jpg&res=medium

Meds go on the back according to time, abnormal labs go under misc, and tubes and lines go under their appropriate system... it makes for a smooth report.

turnforthenurse, MSN, NP · Jul 20, 2011

I cannot take credit for this - I actually found this report sheet here on allnurses in another forum, posted by an RN whom I believe works in progressive care.

I usually just take a piece of paper and fold it in 3-4 and put the room #/last name, first initial at the top of each section and then take report. At the bottom of each section I write down the times for meds (just like 21, 22, 00, etc) and cross them off as I give them. Important meds (such as vanc) I actually write down, since meds like that must be given on time. I think, however, I will use that sheet that RhinoRocketRN posted!

When giving report, I always include:

* patient's name/age

* patient's physician

* admitting diagnosis(es)

* pertinent PMH

* allergies

* code status

* IV's (site & location, such as "22G in LFA" as well as when it was inserted (at our facility, IV's must be changed Q72H), what fluids are hanging and at what rate)

* any tubes/drains (including foleys and what is draining)

* FiO2

* any important labs, including last blood sugar if applicable

* any abnormal assessment data/what happened on your shift.

* if the patient received pain medication on your shift, I always tell them what, the dose/frequency and when their last dose was - I know the oncoming nurse can look it up on the MAR but it helps when someone just tells you instead of fishing for the information.

I also always ask the oncoming nurse if they have any questions or if there is anything I forgot to mention, and they will ask, so that helps. It helps to make sure you don't forget anything (even though I sometimes do!) Because you work in the ICU and work with patients on ventilators, I would also include pertinent information related to the ventilators, including the vent settings (even though we do not touch them, the RRT's do that) and the cm location of the ETT.

As for assessments, I just made a little sticky note of when things should be done and the frequency. I don't know what kind of charting system of hospital utilizes, but our charts are entirely computer-based (including physician orders, which is quite possibly the nicest thing that has been done for nurses - no more having to try to decipher all of that terrible handwriting!). Our assessment flowsheet has all of the categories and in each box another drop-down menu pops up and you just click what applies and what doesn't apply.

JREPORTSHEET3.doc

nursc · Jul 20, 2011

This is very helpful! Thanks so much!!