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Nursing

Documentation

General Policies

  • Patient records require documentation. Hand written progress notes should be in blue or black ink with no empty lines or spaces between entries
  • Only hospital approved abbreviations and symbols are to be used
  • Each entry must include the date, time, signature and professional designation of the writer
  • All documents are to be identified with the patient’s name, history number, date and responsible physician
  • All allergies must be noted (responsibility of nurse who takes patient history)
  • Erasures or alteration of spelling errors are not permitted - draw a line through the incorrect word such that it remains legible. The word “error” is to be marked and initialled.
  • For content errors - record a new entry (with date, time and signature) with the correct information. This entry is to be titled “correct information for entry----------”.
  • For submission in wrong chart - place a diagonal line and write “wrong chart”. Date, time and sign.
  • Illegible entries (e.g. made during a cardiac arrest) may be re-written or re-copied. Original entry must be left in the chart and the new entry labelled as such.

Progress Notes

Progress notes should be written at least once every 12 hours and for each of the following events:

  • Admission 
  • Transfer (e.g. unit to unit)
  • Discharge 
  • Treatment or procedure (e.g. procedure requiring consent or unusual treatment)
  • Change in patient’s or family's condition
  • Patient incident (e.g. medication error)
  • Patient or caregiver education

The purpose of the progress notes is to document the patient response to treatment, illness, and changes in condition, and to provide information and perspective of the professional writing the note. The note is not intended to duplicate what is recorded in other sections of the patient chart, such as flow sheets.

 A.P.I.E. Charting

At SickKids we use a charting format called "APIE" for our progress notes. This acronym stand for:

A - Assessment: subjective and objective data. This is your patient assessment, circumstances, conversations, patient/family education needs etc.
P - Planning: Includes nursing plans, and family goals for treatment. This should not include the plans of other professionals as they will document their own plans.
I - Implementation: What was done?
E - Evaluation: Did it work, how it worked, what changes you need to make if it didn’t work. This is from your perspective as a nurse and from the the patient/family perspective.

Example of a Typical Progress Note in APIE format: Situation: Parent insisting on sleeping in a large bed with their one year old child, rather than placing child in a crib as per hospital guidelines. You are concerned that the child may fall out of the bed, while parent is asleep or when parent has to step away from the bed.

 • A: Mom and patient asleep in bed together overnight. Child cries when mom has to leave for any period of time. Patient is connected to a monitor and has multiple IV lines. Mom says “I always sleep with her at night at home.”
• P: Review with mom safe sleep guidelines, rationale and recommendations. Update preceptor and charge nurse of your concerns.
• I: Discussed safe sleep guidelines for in hospital care. Expressed concerns to parents related to child’s safety, for example if  mother needs to leave bed during the night. Mother states she will continue to sleep with the child. Spoke with charge nurse. Safety report completed. Parents agreed to allow nurses to assess more frequently during the night to ensure safety of patient. Responsible physician notified. Team will speak to parents in the morning and discuss acceptable strategies to keep child safe.
• E: Patient remained safe overnight. (Signature, 4th year Nursing Student, University of Windsor).

Flowsheets

A new flowsheet is to be initiated for each 24 hour period, starting at 00:01am. By signing and initialling the flowsheet, the RN indicates:

  • a safety check has been performed
  • the presence of a correct ID band
  • the presence of an accurate allergy band
  • the documentation of the monitor control number and assessment of appropriate alarm limits
  • the accuracy of all assessment/entries included on the flow sheet at that time

Students and/or other health care professionals providing elements of care sign under ‘Other Caregivers’ whenever care is provided.

Intake/Output section:

  • Hourly IV site/rate check
  • Cumulative IV volume infused hourly
  • Complete description of all IV solutions (solution, name, and concentration of additives), continuous IV infusions (medication name, dose & rate) and parenteral nutrition solutions (e.g. TPN)
  • Medications given (IV, PO, NG, G-Tube)
  • Intake and output must be totalled at least every 24 hours or as ordered, and recorded in the fluid totals section of the flow sheet.

Vital Signs Section:

  • Document vital signs in the space provided
  • Vital signs should be plotted on the graph if they are assessed and charted every 4 hours or more often.
  • Graph the vital signs using the graph legend symbols and assessment legend
Reference: SickKids Policies and Procedures: Documentation