Documentation Reminders

7C Nurses,

I noticed a number of documentation issues this week during chart audits. Specifically, please remember to document pre and post pain scores when giving a pain medication. Also, please choose specific interventions in the Plan of Care section, it is not enough to just initiate certain choices (i.e. initiate Respiratory and not develop the actual care plan). Last, please remember to document ALL I/Os. There were several patients who had 12 to 16 hours with no documentation, and I know some of these patients are infants who must have had wet diapers. At the very least, document occurences for those patients who do not need strict measurements.

PICU Nurses,

Please remember to document pain reassessments every time.

Overall, documentation looks great. I want to note that admission assessments have been especially well done and complete. Thanks!!

--Amelia--