Returning nurse needs help with documentation

try taking a systems approach

CNS: sedation score orientated PCA EPCA other analgesia, call bell explained and at hand

CVS: vitals O2 IV or central lines, date of insertion, IV fluids,IV antibiotics, heart and lung sounds, trachy suctioning how often colour of sputum, nebs, chest tube on suction or not CLAMPS available, deep breathing and coughing exercises explained,

Renal: catheter/PU post op, haematuria, any urinary tract stents, date of planned catheter removal urine dipstick

GIT: NBM, ice, free fluids, NGT, TPN, blood sugars rectal tube, stoma colour (pink, dusky) output, appliance in place, any rod, size of stoma, passing flatus, bowel sounds,abdo soft or distended, nausea

Skin: dressings, wounds and surround skin red/ hard? wound edges well approximated, any dressing changes done? PRESSURE AREAS esp from ICU check heels under TEDS, put in your incident report early for PA's cause otherwise your ward will be blammed. Drain tubes, type colour and ammount of output

Blood results of note and what done to resolve them - low K+ replaced ECG done.

Social: family aware of transfer and educated on visiting times, discharge plans, community services required or rehab or going to stay with family members

Multi disciplinary team: pharmancy, OT, physio, social work, dietican, stoma care, rehab referals made.

The first note from ICU always is a speel I find and then as things are removed there is less to write about.

Obviously not everything is relevant to every patient but that is just a suggestion

Good luck to you :wink2:

don't forget to address some remarks about the reason they are here - for instance, if a respiratory issue document the O2 sats, use of accessory muscles, etc. Don't forget pain scale (probably with CNS review). Document about every tube attached to patient. Good luck!

yep, just chart from the patient's head to toe, detailed review of all systems like above posted. I hated working ICU with the narrative charting. When I worked the floor, we used focus charting, which I loved.

The way I was taught, less is more... Once you get into detail, you better make sure you include every last detail or else they'll wonder why you didnt write everything... Example: You could say (a) safety precautions maintained (which covers everything and saves time and energy) or (b) Siderails up x2, callbell in reach, non-skid socks on, room free of clutter, toileting offered frequently... etc...... but if you forget to mention the bed alarm being on, your nailed.. So if you want to do in-depth notes, just make sure you go all the way and dont sabotage yourself...