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NICU assessment documentation frequency

NICU   (274 Views | 1 Replies)
by Ashley NICU Ashley NICU (New) New Educator Nurse

Ashley NICU has 12 years experience and specializes in NICU.

62 Profile Views; 6 Posts

Nursing staff in our NICU are questioning how often to chart full assessments. 

We do full patient assessment Q3-4 hours. the initial shift assessment is charted in EPIC. EPIC gives the option for "Reassessment: No changes since MY previous assessment" at the top of the Body assessment flowsheet. Some staff feel that after their initial assessment is charted, they can use this selection for the remainder of the 12 hour shift and not document anything else on the body assessment flowsheet. We do chart hourly vitals and IV checks, and document I&O every assessment. 

Most staff feel that we should chart a full body assessment at least every 8 hours, or every other assessment. Our hospital documentation policy is vague. 

Can anyone offer the gist of your hospital's protocol for NICU charting (how often to document)? 

Thank you!

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NICU Guy has 5 years experience as a BSN, RN and specializes in NICU.

2 Followers; 3,705 Posts; 33,344 Profile Views

Moderators- Please merge the two threads together (General nursing forum and this one).

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