PACU charting, please help!!!

pink345 · Jul 24, 2009

I am new to PACU also and have been working in ambulatory surgery for the past 2 months. I am returning to nursing after being away for 9 years (did a refresher course first) but am learning a lot of new stuff each day. We have all electronic medical records, so all of our charting is on the computer (I still have to have a cheat sheet on my clipboard for each patient though because we don't have computers at the bedside yet). It will depend on what system of charting your facility uses but the focus is usually on the following types of assessments: Respiratory and airway status (O2 sats, lung sounds, deep breathing), blood pressure and cardiac rhythm on monitor, rating of pain on 0-10 pain scale and interventions/meds as needed, control of nausea/vomiting and interventions as needed, operative site dressing appearance, temp and if they need bairhugger blanket on, fluid status IV/PO, any DVT prevention like SCDs, level of consciousness, discharge teaching, etc...

It would be good to be familiar with the Aldrete scoring system, you can pull it up online or find it in most nursing textbooks in the surgery chapter. Our charting is a lot of checking boxes and there are also spots for narrative notes if you want to address something that needs more explanation.

Hope this is helpful. Good luck in your new department! :nurse:

roziepig · Jul 27, 2009

Thank you so much for your reply. VERY helpful and considerate of you for taking the time to post some helpful tips.

katkonk, BSN, RN · Oct 10, 2009

Charting by exception and the Aldrete score is what it is all about in PACU. Don't narrative note if things are addressed in the other section (checking boxes in the charting by exception). With outpatients that I am discharging, I always make a note of when the family came to the bedside, for instance, and note the name of the responsible adult that I explained the discharge instructions to and their relationship to the patient. If there is anything that is concerning to me...more drainage than expected, if I think they don't really "get" or are not listening to the instructions, then I note it. If I think there is something important that they may not be compliant with...like yesterday I was sending a very elderly lady home and I knew they were going to leave her by herself most of the day-until her husband returned from his job that evening, I noted twice that I strongly advised them against leaving the patient alone for anytime during the intial 24hour recovery period. If there is more drainage than expected, if the patient has a funky sounding chest and you think they may be coming down with a "chest cold"/viral illness, etc...note the specific deep breathe and cough instructions in your notes. Other than special concerns, it should be all checked boxes. And one of the surgery centers that I work for has a policy of noting that when you took them to the car to go home, that their seat belt was fastened. I adopted that for every place, just because I think it is a good idea. If going to the room and they have a PCA pump, note that you explained that the family member should not press the button for the patient, so that is written down somewhere. You get the idea...just CYA any time you can, in your notes. Also, if there is anything that is especially concerning to you that you noted in PACU, that you really want the floor nurse to check on, and you give that info in report, be sure and note that in your notes. If they had a bad outcome, the nurse on the floor could never say "well that was never mentioned to me, and I was unaware that the patient had....blah blah blah". This, hopefully, will also bring it to the nurses' attention on the floor later, in case they happen to be reviewing your notes. Good luck, and enjoy your PACU days.