Let me start off by saying that I know I should probably already know the answer to this, but I don't. I've been working on a tele/critical care floor for 2-3 months now, and I've asked a few of my coworkers, and have gotten varied, sort of vague answers on this.
My question is, are the head to toe assessments we document every shift ever used by anyone besides ourselves? Does anyone else ever go in and look at them, or are they ever used later?
I am not wondering why nurses do head to toe assessments at all. I get that, and I will often look at the previous nurse's assessments to see if anything has changed or if he/she caught something I missed. I guess what I'm wondering is if they are ever used in the bigger picture of the patient's care. I'm just curious, because I do so much documenting, but I don't really know where it goes or what it does.
You bet other people (including physicians, at least the smart ones, if they know your notes will be worth spit) are reading them, people you never thought about.
. :)
I agree with your entire post and will say that many of our physicians look at the nurses notes.
But I just had to ask. . . spit isn't worth very much so what does this mean??
Some MDs do. I look at what's previously been charted for changes, I think the best nurses do. :)
I think it depends on where you work how much it's actually looked at. I've often wondered how long before anyone would notice if I just stopped charting.
Our attendings read our notes...then they quiz the resident on things that were charted lol The residents then learn they better be looking at what we chart :)
I beg to differ, I recently had a nurse come to me and ask how she should tell a visitor to get to the 4th floor....Duh--the elevator and push the button marked 4. LOL
I know I read other nurses' nursing notes all the time.
In LTC, I'd say many of the orders the physicians write are based soley on the documentation of the nurses. They only assess some of the residents themselves once in a blue moon.
And I've seen our physician copy my monthly nursing summaries word for word as his 60-day summaries.
I know I read other nurses' nursing notes all the time.
In LTC, I'd say many of the orders the physicians write are based soley on the documentation of the nurses. They only assess some of the residents themselves once in a blue moon.
And I've seen our physician copy my monthly nursing summaries word for word as his 60-day summaries.
I consider myself some what of an over-charter but I do see our docs and NPs sometimes refer to my notes, so I know they read them. Like you said in LTC the nurses are the eyes and ears for providers.
Spidey's mom, ADN, BSN, RN
11,305 Posts
I agree with your entire post and will say that many of our physicians look at the nurses notes.
But I just had to ask. . . spit isn't worth very much so what does this mean??