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NICU: Assessment Documentation


Specializes in NICU. Has 13 years experience.

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 their hospital's protocol for NICU charting (how often to document)?


Specializes in NICU. Has 6 years experience.

If the baby is being fed Q3 (9/12/3/6 schedule): full assessment, temp, diaper, feed (9/3). Vitals off monitor, temperature, diaper change, feed (12/6).

Ad Lib feeds: Full assessment, temp, diaper at each feed (Q5 max).

NPO or continuous feeds (Q4 cares): Full assessment, temp, diaper, feed (if continuous) (8/12/4), vitals off monitor Q4 (10/2)