Published Feb 17, 2011
Umrn1
15 Posts
I am a med-surg RN with an IV documentation problem. I don't know if this is right specialty area, but here is my delimma... In our hospital, we use EPIC EMR. When we scan to hang any IV fluid/med bag, we have to leave the patient room and get the patient chart from a little closet just outside the patient room and write in the fluid/med hung along with start date and time and end date and time. My nursing manager and director have explained to me that by keeping a start/stop list of these IV fluids, that guarantees our reimbursement and has saved us a lot of money. If we fail to document start and stop times, we lose money.
I have so much trouble remembering to stop, go to patient chart and write this down. I know it does not sound to difficult, but when I leave the patient room and cross that threshold, I'm off running to another task or patient need. Some nurses have started removing each patient's flow sheet from the chart and carrying them around on their clipboards to remember, but I don't carry a clipboard and find that to be just one more cumbersome problem, and I fear of misplacing the entire sheet.
I am asking what does your hospital do to keep up with start/stop times for IV fluids? There must be an electronic way or at least a more efficient way. Any feedback will be so very much appreciated:o