"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.

[RobLPN]

I don't use "will monitor" because then you must prove with more documentation you did.

[RobLPN]

I also don't use "No change" because if something happens how can you prove no changes unless you assess the pt . For examople, can there be no changes to lung sounds without listening again to say no change.

[marmsgirl]

I guess i need to clarify when i chart at midnight i chart in eyes closed, even resp, repositioning self, no s/sx discomfort, no needs identified,etc.. so when i chart at 2 am (i try chart every 2 hours) if there are no changes in pt condition from past note I put no changes. I am not going to assess lung sounds when pt sleeping, pt get very little sleep already.