TITLE: GUIDELINE FOR COMPLETION OF THE 24 HOUR PATIENT FLOW SHEET

INSTRUCTIONS:

All instructions which have an asterisk (*) beside them are to be completed by the shift leaving at 0700. The Multidisciplinary Admission/Discharge Data base (MADD) must be completed before documentation can be initiated on the 24 hour flow sheet.

Definition of Symbols:

(Ö ) Indicates the standard has been met with no deviations. This symbol may also represent that the activity was done.

(*) Indicates an abnormal finding or deviation from the UAMS standard, protocol, or procedure. A focus note must be written.

(® ) Indicates the abnormal or change has continued.  If first assessment by caregiver, focus note is indicated.

(FS) Indicates a flowsheet is being utilized for assessment of this system, alleviating the need for a comprehensive focus note.

(D ) Indicates an IV site or wound dressing has been changed and that the site remains within normal limits.

The symbols are charted in the small box in each column. The larger box is used for the time using the first 2 numbers of the 24 hour clock, (e.g. 20 for 2000) and the initials of the caregiver.

Empty areas on the form, or parts of the form which are not needed for the patient do not need any notations - simply leave area blank.

Blank lines on the form may be used for charting any extra information needed to cover specific protocols, guidelines or MD orders which will not fit in the labeled spaces.  May also line out unused spaces and write in information, if necessary.

PAGE 1 (1 of 4)

1. * Place MR sticker.
2. *Date
3. Enter initials of the caregiver (legibly).  Each person documenting on the focus notes should initial and sign as a caregiver.
4. Enter name/title of caregiver (legibly).
5. Time of note.
6. Designate area of abnormality, e.g., GI, or protocol charted against or (*) abnormal or change focus note.
7. Briefly write note required.  If meets standard, no note is required.  All notes must be initialed.
8. *Plan of Care - list all protocols and precautions that are in effect.  See list of approved protocols and precautions.  All "non-standard/non-approved" protocols or precautions listed on plan of care require and individualized action plan.

KEYPOINTS:

1. Plan of care must be addressed daily
2. Once protocol implemented, it must be listed until outcomes are met.
3. Document to protocol.
4. Place a copy of the protocol in bedside chart.

9. *Enter date protocol/precaution implemented.
10. Enter date outcomes of protocol are met (Unmet outcomes must be addressed at discharge).
11. Enter time of lab and lab results per unit standard.
12. *Check if transfusion consent signed by patient and in Medical Record.
13. Enter date of last type and crossmatch.
14. Enter date IV/CVL line changed or inserted.
15. *Plan of care reviewed.  Must be reviewed daily.  Protocols remaining in effect are transferred to the next day's flow sheet.

Continued on Page Two/Three

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