Charlotte, I think this debate is going on in every facility - can something that has to be done at prescribed intervals be documented as a single entry, or must it be done be documented every time it is done?
I am seeing it done both ways, sometimes within the same facility. Leadership may determine that one type of care is so high risk, it has to be documented multiple times. Conversely, something that is low risk may be documented once. Both approaches raise further questions. If something can be done many times but documented just once, can the charting be done at any time during the shift, or would it be better to document at the end of the shift, when a nurse can truthfully chart "I did this every hour"? If something is so important it has to be documented repeatedly, when is that documentation going to take place - concurrently, or all at once at the end of the shift? If concurrently, does the nurse's caseload really permit this? Is there enough hardware available to support this goal? If it's going to be documented many time, but doesn't have to be done until the end of the shift, is there any logic to a nurse who is completing a 12 hour shift making 12 entries on the time and date stamp and then recording all entries at the same time? There are many things in a hospital that are supposed to be done every two hours, or every hour, or even every 15 minutes. If all have to be documented every time they occur, and documented real time, that could require substantial changes in staffing, workflow, equipment provisions, etc. So I think choices have to be made. If the manager who made the suggestion that you describe is the manager of the only department that has to document the hourly rounds, then I would tend to side with the manager's view of things. He/she has ultimate responsibility for care and documentation. If, on the other hand, multiple departments are involved, I would bring this issue to whatever committee or channel you have for making decisions like this. Other resources might be the risk manager, quality manager, CNO. One red flag that jumps out here at me is the notion that the nurse is expected to document that the patient was seen when that observation was made by somebody else. I think you might want to talk to risk management for this reason, if none other. Sharon ________________________________ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Charlotte Sent: Monday, July 02, 2007 1:29 PM To: [email protected] 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.
=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*=*= To subscribe or unsubscribe to the meditech-l, visit http://mtusers.com/mailman/listinfo/meditech-l_mtusers.com To check the status of the meditech-l, visit MTUsers.NET For help, email [EMAIL PROTECTED] Please visit and add information to the MTUsers WikiPedia at MTUsers.NET/mwiki ______________________________________ meditech-l mailing list [email protected] http://mtusers.com/mailman/listinfo/meditech-l_mtusers.com
