Charlotte, I can see this from both view points. You are thinking that they need to document every hour. That would seem to match the requirement. Hourly documentation is a challenge as it means for an 8 hour shift, I have to document 8 times, being sure that the last time is close to the end of my shift as I can't document in the future. You are apt to have someone document the last one at 2:30 for the day shift with the next one being documented at 4:00 for the next shift. When we initially started with NUR, we were documenting every hour on observation patients. That became difficult at the end of the shift. We finally got the person who was insisting that hourly documentation was needed to change her stance on the topic. It was much easier on paper. No one could track that you actually documented the 3pm observations at 2:30. The manager is wanting them to only have to document it once. I am not sure that the shift assessment would be the right place for this as the assessment is typically done near the beginning of the shift but I would encourage you to at least consider a way to make it so it only has to be documented once a shift. We have to try to keep this process as easy for the nurses as possible. We keep coming up with more and more things that need to be documented and the nurse at the bedside is feeling that they are spending more time with the computer than they do with the patient. We defined our Restraint policy to require documentation once a shift for the restraint checks rather than required the more frequent documentation. We indicated that the documentation needs to be done near the end of the shift. We audit every restraint chart and if the documentation is done at the beginning of the shift rather than the end, it is reflected in the audit and would be addressed as necessary. We haven't gotten to the point where we are documenting the hourly rounds yet. The other challenge I can see with this is, if the patient is being visualized by someone other than a nurse, how does the nurse know for sure that it happened? Good luck with this.
________________________________ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Charlotte Sent: Monday, July 02, 2007 2:29 PM To: meditech-l@mtusers.com Subject: [MEDITECH-L] [Meditech -L] Patient Care Documentation How are some of you wonderful, kind, caring people handling this: Nursing needs to start documenting that they have made rounds on and/or visualized every patient hourly. The patient can be visualized by a nurse, cna, volunteer, unit secretary, dietary, maintenance, etc. the nurse just needs to document that the patient has been seen. It was suggested by one of the managers that there be a query on the shift assessment that the patient has been seen hourly, but I don't agree with this. Any suggestions????????? Thanks!! Charlotte Snider RN Clinical Coordinator Information Technology Hammond Henry Hospital Geneseo, IL Therapy is expensive. Poppin' bubble wrap is cheap. The choice is yours!! CONFIDENTIALITY NOTE: This e-mail and any attachments are confidential. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of this e-mail or any attachment is prohibited. If you have received this e-mail in error, please notify us immediately by returning it to the sender and delete this copy from your system. Thank you for your cooperation.
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