What are you required to chart?

Published

This is what my hospital (and floor-a step-down unit) requires (we have computer charting):

0800

Head to toe assessment (no charting by exception...all areas must be filled out even if the pt. is "normal")

Education

Safety

IV

Activity

Vitals

Pain

Rhythm strip (interpreted, charted on computer and mounted on paper chart)

1000

Vitals (if pt. is on a drip)

Safety

Activity

Pain

Respiratory check

Education

1200

Blood sugar (if diabetic)

Focused assessment

Rhythm strip (interpreted, charted on computer and mounted on paper chart)

Vitals

IV

Activity

Pain

Safety

Education

1400

Vitals (if pt. is on a drip)

Safety

Activity

Pain

Respiratory check

I&Os

Education

We have a nurse patient ratio of 1:6

Up Vote Up Vote ×
Specializes in CCU MICU Rapid Response.

Hmmm...

Vital signs (AT LEAST) Q4, on a drip they are hourly

Head to Toe assessment (19,23,04)

Activity Q2 hr in the very least

IV site assessment and observation of fluids and rates Q4hr and rate changes, bag changes PRN (19,23,04)

Rhythm strips (19,23,04)

The following items with initial assessment.

Safety/fall risk

Education

Pt belongings

Complied with electrical safety

Care plan reviewed/ and or updated

If they are suicidal; behavior and mentation Q2hr

If on the vent, all that good stuff Q2hr also.

I work in ICU with a ratio of 2:1, I find that I chart the same thing over and over again..... probably more, but all my weary brain can thiink of for now...

Cheers~ Ivanna

Up Vote Up Vote ×
+ Join the Discussion