Please be sure to make a "misc events" note when a patient is transferred to the PICU so there is an admit time documented. If patients come from other floors and the database is complete, it may be difficult to determine when they arrived in PICU. I know we do vitals upon admission, but the only way to determine that vitals were done in PICU is to look at the name of the nurse charting them. With floats, Meduflex and new RN's this can be very confusing to someone auditing the chart.
Also, be sure to document when lines, drains, and airways are removed. We are great at documenting when they are placed and present, but sometimes we miss the removal date and time.
Audits are performed to look at our patient population, their diagnoses and procedures performed while in our units and to determine ways to improve our practice. This information allows us to staff appropriately so it is very important. Let me know if you have any questions, thanks!
Erin
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