"will continue to monitor"

[rnto?]

Say you are writing a general head to toe assessment in the nurses' notes. Nothing is really going on with the patient. (It's a physical therapy rehab unit). If you write "will continue to monitor" at the end of your note, and you do indeed continue to monitor the patient, but nothing changes, do you NEED to write an additional note because you wrote "will continue to monitor". We are only required to chart once per shift.

[Andrew, RN]

I would write "no changes compared to initial assessment of patient" or whatever your facility would prefer you to write.

[MikeyBSN]

You don't "need" to write anything in the chart. However, if one of you patients has a bad outcome and that chart lands on a tort lawyer's desk, I'm sure one line per shift that says "will continue to monitor" will bring a smile to the lawyer's face.

[Straydandelion]

I always write a small statement at the end of my shift just to acknowledge I checked frequently, they were the same and no changes noted.

[nrsman1]

where I used to work we were required to chart every 2hours

[LHH1996]

yes..i would write that nothing changed. don't ever write that you will continue to monitor if you don't plan to write a follow up note...Just Like MikeyBSN said. you don't want the chart to end up in court and it look like you didn't follow up. just my opinion.

[RNperdiem, RN]

I do use a lot of canned phrases in the narrative note when there is not much going on.

A narrative note might contain one or two useful bits of information written in appropriate detail, the rest is fluff and canned phrases thrown in so I can finish up quickly and get back to real patient care.

[MikeyBSN]

Personally, I would not document on a patient any less than ever two hours, even if that patient is stable. If the patient is critical, then continuous documentation is needed. Perhaps this is a different standard than what is used in a rehab unit, but I don't think our documentation standards should be all that different in general. The nurse's note should tell a story. What happened to this person, what did we find, what did we do, how well did it work, and what is the plan for the future.

Although "canned phrases" are often unavoidable, I don't always like to use them. If I do, I supplement them with a more specific aspect. For example, I had a kid the other day who hit his head and threw up twice. Instead of just writing "Awake, alert, oriented X 3", I wrote "awake, alert, pt knows his name, patient knows he is at the 'doctor's', ambulating behind mother with stead gait; swinging spider-man toy above head and laughing."

[blondy2061h, MSN, RN]

"Pt continues to rest comfortably. Assessment unchanged. Report given to oncoming shift."

[mustlovepoodles, RN]

Although "canned phrases" are often unavoidable, I don't always like to use them. If I do, I supplement them with a more specific aspect. For example, I had a kid the other day who hit his head and threw up twice. Instead of just writing "Awake, alert, oriented X 3", I wrote "awake, alert, pt knows his name, patient knows he is at the 'doctor's', ambulating behind mother with stead gait; swinging spider-man toy above head and laughing."

This is excellent charting. As a peds nurse, I often notice that parents perception of a child's illness does not reflect the reality of a child's illness. Accurate charting can save your butt. Mommy may be telling everyone that Jimmy is "lethargic and can't keep anything down", while you see that Jimmy is sitting up in bed playing with legos, interacting with staff, and sipping on a little Gatorade. I chart exactly what the parents tells me("mother reports that child is lethargic, not keeping anything down. RN notes that child is smiling, playing with legos, sipping on 30cc Gatorade, no vomiting, T98.6.) I never chart anything as nebulous as "will continue to monitor." If I don't come back to report an update, it just leaves my charting up for examination.

[Sunflowerinsc, ADN, RN]

"Pt continues to rest comfortably. Assessment unchanged. Report given to oncoming shift."

I don't know about this for charting ,didn't really tell me anything about the pt.

"Continues to rest comfortably" Does that mean the nurse looked in on the pt who was in bed with eyes closed? Or pt is trying really hard not to not have pain. "Assessment unchanged", unchanged from what? "Report given to oncoming shift" Well, isn't that a standard of care,am I going to write that on all my pt's (over and over) If the facility requires this to be charted, wouldn't I write who I gave report to and what it covered with that pt? Treatment, outcomes, ect.

"Will continue to monitor" Monitor for what ,what goal ,outcome was the problem for this shift?

Just some random thoughts ,not to upset anyone! I know charting would have different standards depending on type of pt and facility. I thought the original question was about long term since it stated needed to chart only once a shift.

[blondy2061h, MSN, RN]

I don't know about this for charting ,didn't really tell me anything about the pt.

"Continues to rest comfortably" Does that mean the nurse looked in on the pt who was in bed with eyes closed? Or pt is trying really hard not to not have pain. "Assessment unchanged", unchanged from what? "Report given to oncoming shift" Well, isn't that a standard of care,am I going to write that on all my pt's (over and over) If the facility requires this to be charted, wouldn't I write who I gave report to and what it covered with that pt? Treatment, outcomes, ect.

"Will continue to monitor" Monitor for what ,what goal ,outcome was the problem for this shift?

Just some random thoughts ,not to upset anyone! I know charting would have different standards depending on type of pt and facility. I thought the original question was about long term since it stated needed to chart only once a shift.

That's just my personal tidbit I write before I go. We have to chart a full assessment twice a shift. This is in addition to that. The assessment charting includes teaching and any specific problems, in addition to if the patient is awake, in bed, sleeping, etc.