ICU Standards of Care Documentation

ICU Standards of Care Documentation
This presentation outlines the standards of care documentation in the ICU. It covers the required assessments, monitoring, and documentation at various intervals throughout a patient's stay in the ICU.
0800/2000 Assessment
1
Physical Assessment
Full physical assessment, including vital signs with temperature and pain scale. IV assessment (peripheral/central/arterial) and VTE Prophylaxis.
2
Monitoring
Tube/Drains assessment (JP, Chest tube, feeding tubes), Cardiac monitoring/alarm limits, and ICU Delirium screen.
3
Risk Assessments
Braden scale (pressure sore risk assessment), Morse Fall assessment/override (fall risk assessment), and Fall injury prevention.
4
Patient Care
BMAT (mobility assessment tool), Mobility (turns/HOB), Safe environment, Psychosocial, and Safety equipment at bedside.
1200/0000 Assessment
1
Focused Assessment
Perform a focused assessment, which may use reassessment - "unchanged from previous full shift assessment" if applicable.
2
Vital Signs and Pain
Check and document vital signs with temperature and pain scale.
3
Tube and IV Assessment
Conduct Tube/Drains assessment and IV assessment.
4
Documentation
Ensure care plan is documented/evaluated each shift and education performed/documented each shift.
1600/0400 Assessment
Focused Assessment
Perform a focused assessment, which may use reassessment - "unchanged from previous full shift assessment" if applicable.
Vital Signs and Pain
Check and document vital signs with temperature and pain scale.
Tube and IV Assessment
Conduct Tube/Drains assessment and IV assessment.
Fall Risk
Perform Morse fall assessment/override and implement Fall injury prevention measures.
Every 1 Hour Actions
Vital Signs
Check and document vital signs with pain scale (numerical or NVPS) every hour.
I & O's
Monitor and record Intake and Output (rate dose verify/urine output/tube feeds) every hour.
Every 2 Hours Actions
1
Mobility
Check mobility - turns self vs q2 for immobile patients *movement of devices (SpO2, ETT)
2
IV Assessment
Perform peripheral IV assessment (if continuous drips running)
3
Hygiene
Provide q2 oral care for ventilated/BIPAP/NPO status patients
Event and Vital Signs Documentation
Document patient status changes and provider notifications at time of event.