Timing assessments

[NeuroNP]

We still use paper charting in our ICU. We document assessments q4 and there is some debate over how those should be timed on the flowsheet. For example, do you need to document that the assessment was done at 2005, 0015, and 0358 or is 2000, 0000, and 0400 sufficient? Most of our nurses do the latter, but some have said at a previous hospital they had a charting class that said the former was correct because in chart, an attorney could say, "so you were in the room at PRECISELY 2000, 0000, and 0400?" and could use that to show that you were sloppy about record keeping. Seems a bit far fetched to me, but who knows? Opinions anyone? Hopefully, we'll be using computer charting soon and this will be a moot point.

Thanks!

[meandragonbrett]

I chart in real time.

[detroitdano]

I chart to the minute. Everything is electronic. I'm especially anal with transfusions or codes where you would be able to compare numbers on paper and in the computer. I always chart what the computer had, unless it's a code/arrest or something, then obviously you're far too busy to be looking at both and comparing.

[hodgieRN]

I document on the hour (0800, 1200, 1600). I am not sure if one is better than the other. My argument is...if you chart on the minute and 2 hrs 32 mins go by, then a lawyer could say you technically didn't do a 2 hr assessment. Even if it is electronically noted that I didn't enter it at that time, there is no way to enter it right on the dot. If I entered something at 1413 and timed it for 1400, that doesn't mean I did the assessment at 1413, it just means that is when I was able to enter it. When we did paper charting, I remember people writing 0800, 1200, 1600 on the top. That doesn't mean I am right, just my preference. For meds, I scan and do that on the minute. Codes on the minute too. It's like when Dr write orders...I see some write 1413 or 1417 but most round to the nearest 5 minute interval. Plus, a lot nurses chart when they have time. Sometimes, I can't chart assessments until noon. So, if I chart my 0800 and 1200 at noon, that doesn't mean I didn't do the assessment...that's just when I was able to enter it. :)

[NeuroNP]

Thanks for the responses so far. I'm only talking about routine assessments. Codes, events, etc, I would chart to the minute. And I'm only talking about on paper. For computer, I'd let it time it. I (almost) always chart as I go (unless I'm crazy busy and have to go back and chart after the fact). My only question is, do I need to be anal enough to time those routine assessments to the minute? Drs orders, etc I always chart to the minute.

[hodgieRN]

I don't think so. If you are gonna time something for 1157, then technically your next assessment needs to be 1557 or sooner...anything after that is greater than four hrs. If you are going to chart something, might as well do it for 1200 and 1600. To me, that seems more clear and structured. Plus, if I assess at 1157 and it takes me 4-5 minutes, then 1200 sounds good to me. If I'm doing Q1 hr neuro assessments, I'm not gonna chart 1013, 1113, 1210, 1307. I like 1000, 1100, 1200, 1300. I know you are only talking about paper charting but once you go electronic...I think the new system allows you to chart by the minute in case a change happens. Just yesterday, one of my patients had seizure activity, and that I charted on the minute with the assessment. But routine stuff, I enter it on top on the hour. You'll see with the beacon system...You can open up Q1 min intervals, but then there are 60 columns for each hr and 15 sections for each column. If I do it on top of the hr, I always have everything on page with no need to use the scroll bar.