If it seems like you're always charting during your shift, it may be because you're OVER charting!!
In this special edition newsletter we're going to dig into charting requirements in the CVICU, and debunk some myths on documentation.
**This is not inclusive of every variant of charting in the CVICU, there will be outliers and assessment requirements change based on the status of your patients. The point of this document is to educate around the basic charting requirements in your day to day*
Full Assessment
All body Systems (within the all doc tab)
Priority problems (3)
Goals for shift
Plan of care
Broset/Braden/Morse scores
Skin assessment (under dressings)
Wounds
Pressure Injuries
Incisions
Daily Weight
Foley Care **
Device Tabs and Settings **
LDA Tab
Art line(s) **
Wound Vac **
ETT/Trach **
OG **
DHT **
Central Line(s) **
Dressing(s) **
Drains **
Pacemaker settings **
PA Catheter depth (CM) **
Education and Admission Requirements **
Shift Change Handover:
Trace all lines **
Check drips
5 Rights of medication **
Concentration **
Compatibility **
Device handover/Checklist
ECMO/Centrimag **
CRRT **
Impella(TM) **
IABP **
VAD **
EKOS **
Change Propofol Tubing Q Shift
** Asterix indicates at minimum
Charting Education? What's the requirement
What are the requirements for Charting Education in CVICU?
Learning Assessments is a requirement on admission and should be completed within the first 24 HOURS after patient admission! (If your patient cannot answer the questions, it can be completed VIA Surrogate of a family member).
Education should be documented EVERY SHIFT! This helps us to identify knowledge gaps of our patients and family members.
Blood Administration education is REQUIRED prior to the first transfusion done during hospital admission.
How is charting education being adjusted to fit within your work flow?
Within the 'all doc' tab, a daily reminder will populate within the flow sheet that will take you to the admission requirement to complete, or allow for a comment as to why the information cannot be completed by the patient or a family member.
Admission Required Documentation Admission histories are required to be completed with 24 HOURS of a patient admission.
Unless your patient is intubated, sedated, with no family present, please make a conscious effort to get this documentation started. Just a few questions to get to know your patients!
ECMO Documentation
1. You must document "Start/Stop ECMO Therapy", "ECMO Circuit", and "$ ECMO Therapy Type" at the beginning of each shift.
2. Document Therapy start/stop of the therapy as closely to the cannulation and decannulation times as possible. SHIFT: Handoff Tab. Cannula Assessment, safety checks Every Hour:RPM, Flow, Sweep, Blender Fi02, Pre Ox, Post Ox, Temperatures, assess your dressings and trace your cannulas.
Transducers: we are NOT to be charting on 'functional transducers' within ECMO documentation. You do not flush them, don't chart on them
Assessment
Reassessment of all systems
GCS/RASS Score
** for patients not on any form of sedation**
Interventions
Mouth Care
Cardiac Index/SVO2 **
Temperature (non-device patients)
Zero Transducers **
CDR Charting (No handoff)
JP Drains
Per the discretion of your orders
What is a Re-assessment??
Reassessments are completed after your primary assessment of the patient. Meant to verify the baseline, or discover a new change in your patients status the reassessment is completed at regular intervals through the day. Requirements of reassessment are delineated in this newsletter. This Is also called charting by exception
By documenting 'done' in the reassessment tab, you have verified your confirming that you completed your reassessment and there is NO CHANGE. This fulfills your charting requirement for that body system.
A key point to take away is 'chart the change' only perform full assessment boxes if something changes in that body system. If not, it is appropriate to chart 'done' and move on with your nursing day!
example: Your patient has no femoral devices or perfusion issues, you check your pulses every two hours, but they never change. Rather than charting all of those pulses a 'done' in the column for vascular/perfusion is sufficient charting.
Assessment:
Focused Reassessment
Heart
Respiratory
Vascular/Perfusion on peripheral device patients specifically
Pain assessment
Pain re-assessment is defined in the MAR based on medication type you are administering
GCS/RASS for patients on continuous sedation
Interventions:
Turns/Mobility **
Restraints
IABP Timing assessment
Document the primary timing you are in for the hour, chart the assissted/unassisted numbers
Assessment:
I/O documentation
Anything going in, or leaving your patients body.. every hour **
Temperature
ECMO
CRRT
Device Numbers
IABP, Impella, ECMO, CRRT, VAD
Intervention:
Temperature
ECMO
CRRT
Vital Signs **
Train of Four (TOF)
while patients are on continuous paralytic
Flush all transducers** (CVP/PA/ART)
Speaking of I/O... Quick review?
There has recently been some questions on fluid restrictions. First lets recap what a fluid restriction is.
A fluid restriction is meant to decrease the amount of intake your patient has every day. The most common fluid restrictions we see in the CVICU are
2000mL /24 hours
1500mL /24 hours
Another component we deal with is hyponatremia, in order to combat this, our providers may set a
500 mL free water restriction
It is important to note that the 500mL of free water is INCLUDED in the designated fluid restriction. for example: if your patient is on a 2L fluid restriction with a 500 free water restriction. This means your patient gets 500mL of water, 1500 mL of fluid in 24 hours.
Another common mistake: If your patient is PRESCRIBED boost drinks, these are not taken out of their fluid restriction. if they want more than their prescribed amount, it is deducted. you STILL must chart the fluid intake of the boost!
Unsure? Check in with your provider to find out what their goal is.
