At our facility we have a mix of 8hour staff and 12hour staff. I work med/surg oncology.
We have three columns to chart under. Nights, Days, Evenings
I am a 12 hour and I was taught to fill in the Days assessment when I got on shift and then at 1500 to do the Evening assessment.
The 12 hour day nurses are paired up with 12 hour nights.
When nights comes in at 7pm they only fill out the Nights assessment. Since I did the 1500 assessment they rationalize that they do an assessment 8 hours after mine. They only do one assessment per shift.
I have no issue with charting two assessments. We dont have a policy on charting.
I just wonder if this is an issue with any of you? Do you working 12 hour shifts commonly fill out two assessments? Is this common practice to wait to do an assessment 4 hours into your shift?
We do a head-to-toe assesment every four hours. If the patient goes to CT or surgery or some other procedure, there is an additional assessment when he gets back, even if his primary nurse is with him during that whole time.
Doing an initial assessment takes priority over just about anything else. I don't think it's safe to give a med without first doing a basic assessment. If time is tight (and it usually is at the beginning of the shift) a mini-assessment might come first, followed by a more thorough one.
This is an ICU. On the regular med-surg/tele floor, they do one complete assessment at the beginning of the shift, then a focused assessment every four hours after that. No matter what, even if you work just a 4 hour shift, a complete assessment must be documented at the beginning of the shift.
I'm not sure how any sort of care can safely proceed without first doing an assessment, even if you don't actually have time to document the assessment until hours later.
We chart an assessment at the start of our shift, even if you are only working 4 hours to cover for someone, and we chart a reassessment every 4 hours or if something changes. And the patient has to have a full assessment charted at least every 12 hours. So if you happen to be working a 16 for some reason, you should have 2 full assessments charted.
We all do twelve hour shifts on my unit but are still required to have an assessment done every 8 hours, this results in day shift doing two (0700 and 1500) while nights does one (2300). Most of the night shift nurses do their assessment closer to 2000, just before their 2100 med pass. Then do notes later in the shift to address problems and a "mini" assessment about 8 hours in to go over everything again. Some nurses prefer doing a mini assessment at the start of shift and then doing a full assessment closer to 0000 and then following up with notes later.
I do my assessments first because I want to have a baseline so four hours later I know if something has changed. If I pick up patients at 2300, I do a complete assessment on them then and a mini assessment later.
You do a complete assessment on each pt. at the start of your shift, and add comments as necessary. End of story. If your facility has different rules, I would ask why.
HollyHobby
157 Posts
We do a head-to-toe assesment every four hours. If the patient goes to CT or surgery or some other procedure, there is an additional assessment when he gets back, even if his primary nurse is with him during that whole time.
Doing an initial assessment takes priority over just about anything else. I don't think it's safe to give a med without first doing a basic assessment. If time is tight (and it usually is at the beginning of the shift) a mini-assessment might come first, followed by a more thorough one.
This is an ICU. On the regular med-surg/tele floor, they do one complete assessment at the beginning of the shift, then a focused assessment every four hours after that. No matter what, even if you work just a 4 hour shift, a complete assessment must be documented at the beginning of the shift.
I'm not sure how any sort of care can safely proceed without first doing an assessment, even if you don't actually have time to document the assessment until hours later.