Report from parents.

I usually ask them if there is "anything new or exciting". Has he been to the doctor? Are there any new orders? Did anything unusual happen since I last saw him? Be sure to chart these things.

I would want to know, in general, whether he had a good day or whether he had any special problems. For someone who has frequent seizures, for example, I would want to know if he had a lot more today than usual, or if any were different than his usual. Was Diastat needed?

Has he needed anything for pain? 

I would ask if he was given any of his PRN meds, when, and why. The when needs to be specific if it was recent enough that I wouldn't be able to repeat it anytime soon. Be sure to chart these in your nursing notes.

If you're working nights and child is already asleep, ask the parents how best you can assess him. Some kids are light sleepers especially at first. You may want to carefully get a temp with an infrared thermometer, pulse & SpO2 off the pulse oximeter, and count respirations. Use a warm stethoscope to check lungs and cardiac - but without moving him.

You need a head to toe assessment, but only within reason. If he's asleep and his problem is pulmonary, concentrate on that and don't worry about assessing his skin, for example, (other than color, temp, cap refill).

The agencies that I have worked for had 2 types of paper charting (2 pages). The first - usually called the flowsheet - is for the head-to-toe assessment. It has mostly items to check off, or a line to fill in. Much of it is repetitive. If the client had contractures yesterday, chances are he has them today! And it will ask for the lung assessment, etc. The second page is a blank page to write in your hourly notes. 

Somewhere in your charting, you need to specify that the emergency equipment is available and ready to use. (Oxygen, Go-Bag, Ambu (BVM), spare trach, etc.) There is usually a spot on the flowsheet for these.

You always need to write something every hour, or the insurance company - including Medicaid - will claim the client doesn't need nursing care. If he is sleeping quietly, you can chart that, and that you are monitoring his respirations, his SpO2 is _______. Respirations quiet & easy (if they are.)