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I am used to head to toe assessment initially, q1hr VS unless on a drip then Q5-15 min. Chart Q1hr for updates, interventions, and outcomes as needed. Now I am getting used to computer charting Q1hr and when needed. I have to admit I still prefer the paper flow sheets. Also chart at least Q4hr. cardiac rhythm, lung sounds. It just depends on the acquity ,stable patients maybe chart q2 hrs, unstable is continuous.
anybody has an good example of a healthassesment assignment,,,could u please forward to [email protected]
Stargazer
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Hi, all. Due to some consistent problems with complete and timely documentation--of both assessments and interventions--on our ICU patients, I have designed new ICU flowsheets for our facilities and would like to take the opportunity to set some guidelines on assessment and charting.
For example: Head-to-toe assessment at least q8 hours; pts admitted with cardiac or respiratory dx to have CV/resp. assessments charted at least q4 hours; unstable neuro q1hour; stable neuro q2 - 4hours; and so on.
I want to set reasonable guidelines that won't come back to bite us in the butt, i.e., nurses being cross-examined in court as to why they "weren't following institutional guidelines" because the guidelines were too stringent or not realistic to begin with.
Do you have these kind of guidelines in your unit, or is it just "per doctors' orders"? Does JCAHO have specific requirements for ICU charting? (I searched their website, but couldn't find what I was looking for.)
Any advice, help, comments, links appreciated. Thanks! :)