Student/Instructor Documentation

Jan Malone 8th floor Nurse Educator

Importance of Documentation• Helps us track our patient’s progress• Conveys information between disciplines and

shifts• Can determine therapy• Is part of the permanent record• Is part of Quality Audits which can drive

improvement initiatives

Student Documentation• Any of the areas of the Vital signs/intake and

output tab except for hourly IV site checks, blood glucose, glasgow, falls, and pain scores. The exceptions require RN assessments.

• All areas of the ADLs in the Pediatric Assessment tab because no assessment is involved.

• All Nutrition by Nursing in the Pediatric Assessment tab.

What not to Document

• Physical assessments• Pain scores• IV site checks• Braden scores• Pediatric Falls Safety

Why can’t Students Document Assessment Items?

• Initiatives and Quality Audits are conducted to determine improvement strategies: PUPS, IV infiltrates, pain reassessments.

• RNs are evaluated yearly on their charting• Once students leave for the day, information

cannot be changed by the RN if something is incorrect.

Vital Signs/Intake and Output

Students must notify abnormals and document “RN notified” with RN’s name.

Verify equipment used for patients’ weights. Options include infant scales, bed, stand, stated, and estimated

Measurements

• Document length, wt., and head circumference on all admissions < 3yrs.

• Document ht. and wt. on all children > 3 years.• Infants < 1year are weighed on nightshift and

all others are weighed on dayshift before breakfast unless a physician specifically orders a time.

All patients who cannot or will not turn themselves, need to be turned q 2 hrs. and document the position.

Charted on admission and as ordered.

Instructor Co-signs all entries, not just at the end of the shift

Students can document all intake: IV, IVPB, orals, tube feedings, free water. Instructor needs to review and co-sign. IV fluids and continuous tube feeds should be documented q 1 hr. and all others as given.

Options for Urine• Note the option “urine”

which can be used for voiding per self and for foleys. Please annotate if the urine was from a foley.

• Diapered children who void and stool at the same time should have volume amt charted as “diaper,” and continue to chart 1 stool and 1 urine.

• Multiple sources of urine should be charted separately: foley, suprapubic, stent…

Students should notify the RN if a patient has not voided in 4 hrs. Oral intakes and outputs are charted q2 hrs.

Hydration Evaluation

• Notifying the RN if patient has no urine output alerts the nurse to start evaluating hydration status: how much oral is taken in, are they tachycardic, how are the BP’s?

• Young patients should void at least their kg. wt. an hour. Older patients should void at least .5cc/kg/hr.

• Frequent and prompt documentation with evaluation can prevent adverse events.

Bring on the ADLS

Pulse ox site needs to be changes once per shift. Pericare is done on pts. with foleys. If a patient is incontinent and needs cleaning, chart “perineum” care under Hygiene not pericare.

Difference between: Menstruation is normal and vaginal bleeding is abnormal. Drop-down box for vaginal bleeding has descriptions for the flow: clotted, scant, moderate, and heavy.

Students should notify nurse/CP so the issue can be addressed later in the shift.

Students should document ambulating patients by duration in time and can annotate how many times around the unit.

Infants also need documentation of activities or repositioning q 2 hrs. If activity or repositioning is not documented, then it looks like the infant has remained in his crib all shift without movement.

Nutrition by Nursing

Challenges with Nutrition

• Some parents order more food that normal because child has been picky and parents are trying to get them to eat something.

• Some order more to share with the patient.• Pediatric patients order from room service whereas

adults have standard trays.• Most precise way to evaluate nutrition status would

be to chart the total of only the foods that the patient tried to eat.

Summary

• Charting is a form of communication between staff. Charting helps us to document our patients progress and need for treatment. Therefore, accuracy is essential for safe, quality care and should be a joint effort between students, instructors, and staff.