Tech vital sheets from unit/other papers

[Ele123]

I'm new at this. My unit provides sheets for us to record vitals, fsbs, drains, and diet pt eats. Each pt. has a row and their row splits in two for two different sets of vitals. Does anyone else's unit provide a sheet? Our sheet is in a different order than what the vitals are charted in the computer and there is no space for writing I & O, carbs, % eaten, baths, dressing changes, discharge. Has anyone made their own sheet? Would this really bother the nurses if it is what all aides use on the unit? Should I just get in the habit for charting them in a different order? What if I just made a second sheet/chart for the rest of those?

[funtimes]

I don't think making your own sheet would bother Nurses as long as the information that needs to be charted gets charted.

[applejackcrunch]

Okay, so just for a bit of background... I did an internship with an HIM department this past spring, which included a lot meetings about changing forms that nursing and techs use- something that I had no idea would have such strict rules for changing or merging or removing them from use in health records. If these vitals sheets are entered into the patient record you need to talk to your supervisor before doing your own thing. Some facilities have very strict rules about forms that are included in the patient's legal health record (for good reason). If you're just using them for your own reference and you're transposing it right into the electronic record then it might not be a big deal. I'd recommend to stay on the safe side and check first though.

[Jaykalkyn, BSN, RN]

I agree with applejackcrunch. My unit has a form that is quite easy, though the order is also different from the electronic record. We rencently ran out of the other form and had to use another form that was handmade, it really sucked. For us, I don't think it matters because the nurses didn't say anything about the handmade form when we gave them their copies. But I would definitely check with the charge nurse or other nurse to see what their thoughts are. After we are done with our shift, ours goes in the shredder anyway.