Download And Paper Documentation Frequency Checklist Disclaimer: This

And Paper Documentation Frequency Checklist
Disclaimer: This checklist is not all inclusive and is not a substitute for your nursing judgment. Please refer to the
appropriate KU Hospital Standard of Practice for further information at http://intranet.kumed.com/body.cfm?id=285
On Admission
 Initial VS and weight within 15 minutes upon arrival to unit (MS VS) (1)
 Initial assessment upon arrival to unit and documented within 4 hours (MS Assess) (1)
 Patient Profile within 24 hours of admission (Navigator – Admission) (1)
 Include last 24 hour I/O’s from outside flowsheet if not part of the O2 system (i.e., from ED, OR, transfer) (1)
 Initiate Patient Problem List, IPOC Cover Page and IPOC with 8 hours of arrival to unit (Paper form – in
chart) (1, 2)
What to document Q1o 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 05 06 07
 Record rates of continuous IV fluids and enteral feedings (I/O or IV MAR) (1)
 Restraint – early release – observe and interact with patient (MS Restraints flowsheet) (10)
What to Document Q2o 08 10 12 14 16 18 20 22 00 02 04 06
 Turn, reposition (MS VS), provide skin care (MS Assess) (1,12)
 Document restraint care – offer foods, fluids and toileting; Check skin color, distal pulses and cap refill (MS
Restraints flowsheet) (10)
 Chart Check (Paper Chart) (17)
 Acknowledge Orders as part of Chart Check (Patient Summary) (17)
What to Document Q4o 08 12 16 20 00 04
 Document vital signs (HR, monitored rhythm, BP, RR, Temperature, and SpO2) (MS VS) (1)
 Peripheral IV site assessment (Lines flowsheet) (1, 6)
 Physical Assessment (refer to SOP for more information) (MS Assess) (1)
o Skin: color, temp, moisture, turgor, mucous membranes
o Neuro: LOC, orientation x 4, Glascow Coma Scale
o ENT: redness, swelling, discharge, ability to swallow, etc.
o CV: heart sounds, HR and rhythm
o Resp: bilateral breath sounds, respiratory pattern, effort, and symmetry
 Chest Tube Drainage (I&O Flowsheet) (1)
 Record output from indwelling urinary catheter (I/O – foley catheter) (1)
 Document dose associated with each IV infusion (IV MAR) (1)
 Assess Naso/Orogastric Tube characteristics – aspirate GI contents and test for pH (7)
 Tube Feedings – flush feeding tube with at least 30ml warm tap water with continuous feeding (Lines
Flowsheet) (13)
 Pain (reassessment documentation varies from 15, 30, 60 minutes depending on intervention) (MS VS) (8)
 Restraints ROM (MS Restraints flowsheet) (10)
 Assess and document patient’s rhythm (MS Assess) (14)
What to Document Q8° 08 16 00
 Tolerance to tube feedings (Progress notes) and residuals (Lines flowsheet) (13)
 Flush Intermittent CVC (I/O flowsheet) (3)
What to Document Q12o
 Complete physical assessment at the beginning of each shift (MS Assess) (1, 12)
 Print rhythm strip at the beginning of shift and minimum of one additional time during shift and review alarm
limits (Paper form – place in chart: 2 strips per shift) (14)
 Temporary Pacemaker: document underlying rhythm, sensitivity threshold, stimulation threshold and
pacemaker site (MS Assess) (15)
 Central venous catheters assessment (Lines flowsheet) (3)
 Braden Scale Score (MS Assess) (1,12)
 Assess for presence of Pressure ulcers (Wounds flowsheet) (1, 9)
 Morse Fall Risk Assessment Tool (MS Assess) (1, 4)
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Assess wounds: type, location, color, drainage and dressing changes (Wounds flowsheet) (1, 9)
Assess stomas: location, color, drainage, etc. (MS Assess and/or Drains flowsheet) (1)
Restraints – document mental status and nursing interventions (10)
Intake and Output: 12-hour totals @ 0600 and 1800 (I&O Flowsheet) (1)
Other tube/drain output (i.e., NGT/OGT, surgical/wound drains, Ostomy/stool) (I&O/Drains Flowsheet) (1,13)
Frequency, quantity, quality of BM (I/O flowsheet and/or MS Assess) (1)
Placement and insertion site of abd tubes (OG/NG, small bowel feeding tube, drains) (Drains flowsheet) (1)
Placement and insertion site of feeding tubes (Lines Flowsheet) (1, 7)
Document type of diet (MS Assess) (1)
Update paper IPOC sheet (in Chart) (7)
Severe Sepsis Screening (MS VS) (1)
IV Line Safety with shift change (MS Assess) (11)
Bedside Safety Check with shift change (MS Assess) (11)
What to Document Daily
 Weight (in kg @ 0600) (MS VS) (1)
 Intake and Output: 24-hour totals @ 0600 (I&O Flowsheet) (1)
 Personal hygiene (MS Assess) (1)
 Address discharge planning (Progress Notes) (IPOC) (1)
 Initiate Daily IPOC (Paper Form – in Chart – Night Shift to Initiate Daily) (1)
 Document patient/family education minimally every 24 hours (Paper IPOC – in Chart) (1)
 Change IV Fluid Container. Label and document date and time initiated. (MS Assess – IV Lines Safety) (3, 6)
 Change TPN and lipid tubing. (MS Assess) (3)
 Change closed feeding system and intermittent feeding bags/tubing/syringes (MS Assess) (13)
 Restart IV inserted in emergency situations or from outside institutions within 24 hours or as soon as the patient
has stabilized (Lines Flowsheet) (6)
 Obtain a new preprinted order form for Restraints (Behavioral Restraints Flowsheet) (10)
 Wear Vocera badge and Locator at all times (14)
 24-Hour Chart Check (Paper Chart) (17)
Standard of Practice References:
(1) Assessment, Progressive Care Patients
(2) Interdisciplinary Problem List and Plan of Care
(3) Central Venous Catheter, Care of the patient with
(4) Fall Risk Reduction
(5) Hemodynamic Monitoring
(6) Intravenous Access, Peripheral Access and Care
(7) Naso/Orogastric Tube, Insertion and Maintenance of
(8) Pain, Management of the patient with acute/chronic
(9) Pressure Ulcer Wound Care
(10) Restraints, care of the patient in
(11) Shift Report/Transfer of Care Report – Nursing Addenda
(12) Skin care
(13) Tube Feedings, Care of the Patient Undergoing
(14) Telemetry Monitoring, Care of a patient requiring
(15) Temporary Pacemaker, Care of the patient with Transvenous and Epicardial
(16) Sheath Removal/Post Sheath Removal, Care of a patient undergoing Femoral Arterial-Venous
(17) Chart Check (Daily/24 Hour)
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