Nursing Documentation Changes
and Reminders
CCTC Nursing Documentation
Change #1
Standard pH range changed to match new RRT documentation
Change #2
Clarification for documentation standards for IV solutions.
Change #2
Record each central and peripheral site:
R IJ Introducer
R IJ Double lumen
Brown
White
Blue
L forehand #18 peripheral
Document legibly the following
3 pieces of information for each
central and peripheral IV
LUMEN:
1. Side of body
2. Insertion site
3. Type of catheter
Change #2
Clarification for documentation standards for IV solutions.
R IJ Introducer
R IJ Triple lumen:
Brown
White
Blue
L forehand #18 peripheral
0.9% normal saline
CVP 0.9% normal saline with 1,000 units heparin
TPN
Levophed in D5W
Saline lock
Record ONLY the SOLUTION and MEDICATION ADDED. This documentation
identifies where solutions are running. If you change either the site, solution or
medication, you must make a DAR entry to indicate the change.
DO NOT record the rate or drug dose; this is already documented on the graphic
record. If you document the rate or dose here, you must make a DAR note any
time the rate or dose is changed.
Change #3
Confirm each shift by a checkmark that the Admission and NEW
Daily checklist for a pregnant patient have been activated and
reviewed (obtain under “P” from Protocol Link of CCTC Website).
Change #4
Confirm each shift by a checkmark that the NEW Postpartum
Admission and Q shift checklists have been activated and reviewed
(obtain under “P” from Protocol Link of CCTC Website).
Reminder:
Remember that this should be completed for any female patient of childbearing
years, not just patients with obstetrical diagnosis. “No” should be confirmed by a
pregnancy test or prior hysterectomy. If confirmed by reason other than pregnancy
test, a * and DAR note should be completed with the initial documentation of “No”.
This assessment is a reminder to rule out pregnancy in all females of child bearing
years. Most females admitted via ED are screened prior to CCTC admission;
check in Power Chart for results.
For any appropriate patient who has not been screened, the need for screening
should be raised during rounds, and the discussion/decision documented.
Change #5
Confirm at the start of each shift that patients have a current blood transfusion
sample on hand. If blood is no longer required, you can enter “not required” on
the line for “Expires”. All patients require an initial sample and completion of
transfusion consent process. Note that all patients at risk for bleeding or who may
require any blood product should have a current sample.
Important Blood Sampling Reminder:
NEVER draw the confirmation sample at the same time as the initial Blood
Transfusion Lab sample…this is a very serious POLICY VIOLATION that can lead
to FATAL transfusion errors.
The confirmation sample is required any time a patient does not have prior Blood
Transfusion Lab history and must be obtained during a completely separate
blood draw event.
The confirmation sample is collected to “confirm” that the blood group identified
during the initial sample is the same as during the confirmation sample. If either
sample was drawn from the wrong patient, a mismatch will alert the lab. The error
could be the original sample (which could have been drawn many years earlier) or
the confirmation sample. Drawing both samples at the same time places patients at
serious risk….mislabelling of blood transfusion samples DOES happen in CCTC!
Fatal transfusion reactions can occur following administration of only a few mls of
the wrong blood group.
CCTC 24 Hour Flowsheet:
Reminders and Future Updates
Reminders Re Line Documentation on CCTC Flowsheet
Be sure to enter the date of insertion. Be sure that the location of line insertion (e.g., CCTC,
ED, OR, IR, other) is documented at the time of admission/line insertion on the line tracking
record (the next revision of the flowsheet will eliminate the need for the line tracking record).
The best time to obtain ACCURATE information about lines inserted pre-CCTC is from the
admitting team. It should be assumed that lines inserted in the ED or the OR when a patient
is hemorrhaging or unstable will need to be changed, unless there is clear documentation
by the physician who inserted the line of the technique.
Reminders Re Line Documentation on Flowsheet
Remember to document when dressings are changed and if there are issues with
any line (e.g., positional, blocked, dressing adherence).
All line issues require a DAR note and should be reported during rounds. The
issue, discussion and plan must be documented in the DAR.
If an emergency line does not get changed following the initial discussion, this
should be documented and passed on to subsequent shifts. Remember, if there
is no documentation that line issues were reported in rounds, it means the
discussion didn’t take place.
FUTURE changes with next revision to CCTC
Flowsheet:
•
•
•
•
•
A column will be added to identify location of insertion (e.g., by
CCTC, OR, ED, IR or “other”)
Columns will be added to identify whether there is documentation
that insertion bundle requirements were MET or unknown/unmet
When the revised flow sheet is available (several months away),
the existing line tracking sheet that records line insertion details will
be eliminated
Until that time, please ensure that the line insertion location and
circumstances are documented correctly and the line tracking sheet
is up-to-date
Any lines where insertion circumstances are unknown/unmet
should be changed as soon as possible, and within 48 hours. Be
sure to document the issue, discussion and plan from rounds.
Future changes in next graphic revision:
Inserted by:
CCTC, OR,
ED, IR,
Other
Insertion bundle
Documented
Unknown
/unmet
List all central and peripheral
venous and arterial lines