UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
MEDICAL CENTER

GUIDELINE
GUIDELINE:              R
EFFECTIVE:        10/03
REVISION:
APPROVAL:        10/03

TITLE:            GUIDELINE FOR PCT DOCUMENTATION USING THE 24 HOUR PATIENT FLOW SHEET (MR# 407)

INSTRUCTIONS:

General information:  The PCT is expected to document in the following areas:  Activities of Daily Living, Physical Restraints, Vital Signs, Safety Measures (ID band), Intake and Output, Weights, and Glucometer checks.  Some information documented on the flow sheet will also be entered into eChart.

  1. Write in patient diet.  If changes during the day enter change in meal box (ex. Patient was on a full liquid diet for breakfast and a reguarl for lunch.  The change in documented in the lunch box ' "reg" and the percentage eaten).

  2. Check if on a calorie count (follow procedure by noting amount eaten on menus - save for dietician).

  3. Enter percentage of diet taken and initial.

  4. List snack (ex.  1/2 sandwich, orange) + time/initials.

  5. Activity (ex. Bedrest, Up tid, Up in chair, up as tolerated)

  1. If bedrest - list only once per shft, time and inital box.  Be sure to turn patient q2hr if unable to turn self.  See #9.

  2. If up "as tolerated" document when out of bed (oob).

  3. Up in chair - note times up in chaird.

  4. Ambulate TID - note times and initial box.

  1. Hygiene-even if patient refuses must document that bath was offered.

  1. If "self" note time and initial.  Enter time of bath and initial.

  2. Assisted or complete - note time and initial.

  3. If refused, enter time offered, "refused" and initial

  4. If requires bath more frequently secondary to incontinence, etc. note times that hygiene done and initial.

  1. Safety - If patient meets the safety standard (bed in low position, top 2 bed rails up and call light within reach) check (√) small box which means meets standard and time/initial.  If patient needs increased safety measures, such as 4 rails, not in box.  Initial time checked.

  2. Anti-embolitics - (TED/SCDs) Document times "off" and "on" and initial.

  3. Turn q 2 hours.  Any patient who is unable to turn self or is in restraints, must be turned at least every two hours.  Document "B: - back, "L" - left side and "R" right side.  Time and initial box when turned.

Restraint documentation (RN must assess circulation/mental status)

  1. Use for patients on Med/Surg Restraint Protocol (Behavioral Management requires separate form), - record when range of motion done (should be every two hours).  Enter time and initials when done.

  2. Skin care and hygiene.  Patients should have skin cleaned beneath the restraints and condition of skin noted.  Report any reddened areas to nurse for assessment.  Enter time and initials when done.

  3. 12-17 Vital Signs

Document value of vital sign under appropriate time slot.  If frequent VS are recorded, may split the boxes.

  1. Pulse ox - document time, % oxygen saturation (oxygen in use, + or -)

  2. Initial vital signs

  3. Date

  4. Allergies should be listed daily - "multiple" is not acceptable.

  5. Check for presence of patient ID band.  Check to see if leible, replace if not.

  6. Check for presence of blue "high risk safety" band.

  7. Check for presence of allrgy band.

  8. Enter glucometer reading under appropriate time.

  9. Enter urine dipstick reading for glucose, acetones.

  10. Record oral intake.

  11. Record total intake for D shift @ 1400.  Initial and enter total in eChart.

  12. Record total intake for D shift @ 2200. Initial and enter total in eChart.

  13. Record total intake for N shift 2 0600.  Initial and enter in eChart.

  14. Record amount of emesis.  Note if guaiac.  Initial.  Total at 1500, 2300 and 0600.

  15. Record number of stools or amount if liquid.  Initial  Guaiac if indicated and initial.  Total at 1400, 2200, 0600.

  16. Record urine output in ml at each voiding.  If has catheter empty and record at 1400, 2200, 0600.

  17. Record total urine output for D shift @ 1400. Initial.  Record in eChart.

  18. Record total urine output for E shift at 2200.  Initial.  Record in eChart.

  19. Record total urine output for N @ 0600.  Initial.  Record in eChart.

Other output may include chest tube drainage and davol drains.  List and measure all of these separately.

  1. Empty and record amount of drainage in Davols, etc.  Total at 1400, 2200, 0600).  Initial.

  2. Total all of "outputs" for D shift at 1400.  Initial.  Enter in eChart.

  3. Total all of "outputs" for E shift at 2200.  Initial.  Enter in eChart.

  4. Total all of "outputs" for N shift at 0600.  Initial.  Enter in eChart.

  5. Record total output for 24 hours.  Record on new flow sheet. (40)

  1. Ensure date is on flow sheet.

  2. Record weight (either in pounds or kilograms per unit specifications)

  3. Transfer weight from day before.

  4. Check to see patient label affixed to chart.

  5. Sign name and initials legibly, once per shift.

 

 RESOURCE PERSON(S):           

 

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