I have a question regarding ICU documentation for HCA nurses and/or Meditech users:
How often and how are you documenting your pt assessments? Full head to toe "shift" assessments as well as "focus" assessments?
We have always done Q6 "Shift" assessments, and added in any additional focus or task list issues along with narrative notes as needed. Now, we are being asked to do a "Shift Assessment" at the beginning of the shift and Q2 "focus" assessments regardless of whether there is a change.
(Oh, and we don't have the F5 function available.)
So I'm wondering if this sounds like what other ICU's are doing and if this sounds right?
I've been trying to find any "standard" regarding frequency of assessments (on the BNE site, we're in Texas, AACN, AJCC, Google, anything) and I can't find anything and our facility doesn't have a policy for ICU documentation. Any help?
Blah!! This is my first job with an HCA hospital and Meditech and so far it's awful!! So unuser friendly than what I am use to!! We do one a shift head to toe assessment (8am) then 12 and 1600 pt notes as reassessment. We have no option to copy and paste, I guess that's what the F5 function a previous poster had mentioned was. The only thing we do document under a reassessment is skin. Skin Reassessment is mandantory under the reassessment section. We also document Q4 hour cardiac telemetry strips both on paper and on the computer.
We do also have paper flow sheets for drips, VS, pain assessments, and Glasgow scale. We then put I&O totals in the computer from the flow sheets. VS are also transferred over via the monitor section too. Seems like a lot of duplication in charting.
We have MT6. I was taught to chart on everything at least once on my shift, with the exception of the vital signs, vent checks, CVP (these must be done every 4 hours) on the computer. We still have to chart the vitals every 1-2 hours on the flow sheet, along with the CVP and vent checks. I hate double documentation! Also, we have to do a modified assesment every 4 hours (neuro, cardio, resp assessment). It's a lot of charting and I hate it!!! Wish I could spend my time actually caring for my patients than doing charting. Anyway, I know it'll keep my butt out of jail in the long run!
We're just starting with MediTech and I agree with the previous poster--it is certainly NOT user-friendly. I've used another system at another facility and it was great! MediTech is very cumbersome--when vitals, labs, etc need to be charted for meds you have to click to four different areas just to chart all the info needed. At my other facility all the info required was right there on one page. Still clicking but not to different pages. What a waste of time when I could be caring for my patients!! :-(
I'm a travel nurse and the hospital I'm at uses meditech. I like it, but I do not like the "nursing note" aspect as I think it is double charting. If we work 12 hours, we chart a full assessment twice. As stated before, there are the q2hr and q1hr vitals, ect, or any changes.
I have a question regarding ICU documentation for HCA nurses and/or Meditech users:
How often and how are you documenting your pt assessments? Full head to toe "shift" assessments as well as "focus" assessments?
We have always done Q6 "Shift" assessments, and added in any additional focus or task list issues along with narrative notes as needed. Now, we are being asked to do a "Shift Assessment" at the beginning of the shift and Q2 "focus" assessments regardless of whether there is a change.
(Oh, and we don't have the F5 function available.)
So I'm wondering if this sounds like what other ICU's are doing and if this sounds right?
I've been trying to find any "standard" regarding frequency of assessments (on the BNE site, we're in Texas, AACN, AJCC, Google, anything) and I can't find anything and our facility doesn't have a policy for ICU documentation. Any help?
We have went to HMS with Citrix as the server. We were using Meditech. Everything is pretty much point and click. We do qshift assessments, but there are IV assessment, IV titrations, and pt rounding documentation that is done q1h. It has taken some getting used to but it is not a bad charting system.
RunninOnCoffee
134 Posts
Blah!! This is my first job with an HCA hospital and Meditech and so far it's awful!! So unuser friendly than what I am use to!! We do one a shift head to toe assessment (8am) then 12 and 1600 pt notes as reassessment. We have no option to copy and paste, I guess that's what the F5 function a previous poster had mentioned was. The only thing we do document under a reassessment is skin. Skin Reassessment is mandantory under the reassessment section. We also document Q4 hour cardiac telemetry strips both on paper and on the computer.