Student/Instructor
Documentation
Jan Malone 8th floor Nurse Educator
Importance of Documentation
• Helps us track our patient’s progress
• Conveys information between disciplines and
shifts
• Can determine therapy
• Is part of the permanent record
• Is part of Quality Audits which can drive
improvement initiatives
Student Documentation
• Any of the areas of the Vital signs/intake and
output tab except for hourly IV site checks,
blood glucose, glasgow, falls, and pain scores.
The exceptions require RN assessments.
• All areas of the ADLs in the Pediatric
Assessment tab because no assessment is
involved.
• All Nutrition by Nursing in the Pediatric
Assessment tab.
What not to Document
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Physical assessments
Pain scores
IV site checks
Braden scores
Pediatric Falls Safety
Why can’t Students Document
Assessment Items?
• Initiatives and Quality Audits are conducted to
determine improvement strategies: PUPS, IV
infiltrates, pain reassessments.
• RNs are evaluated yearly on their charting
• Once students leave for the day, information
cannot be changed by the RN if something is
incorrect.
Vital Signs/Intake and Output
Students must notify abnormals
and document “RN notified” with
RN’s name.
Verify equipment used for patients’
weights. Options include infant scales,
bed, stand, stated, and estimated
Measurements
• Document length, wt., and head
circumference on all admissions < 3yrs.
• Document ht. and wt. on all children > 3 years.
• Infants < 1year are weighed on nightshift and
all others are weighed on dayshift before
breakfast unless a physician specifically orders
a time.
All patients who cannot or will not turn
themselves, need to be turned q 2 hrs. and
document the position.
Charted on admission and as
ordered.
Instructor Co-signs all
entries, not just at the end
of the shift
Students can document all
intake: IV, IVPB, orals, tube
feedings, free water. Instructor
needs to review and co-sign. IV
fluids and continuous tube feeds
should be documented q 1 hr.
and all others as given.
Options for Urine
• Note the option “urine”
which can be used for
voiding per self and for
foleys. Please annotate if
the urine was from a foley.
• Diapered children who void
and stool at the same time
should have volume amt
charted as “diaper,” and
continue to chart 1 stool
and 1 urine.
• Multiple sources of urine
should be charted
separately: foley,
suprapubic, stent…
Students should notify the RN if a patient
has not voided in 4 hrs. Oral intakes and
outputs are charted q2 hrs.
Hydration Evaluation
• Notifying the RN if patient has no urine output alerts
the nurse to start evaluating hydration status: how
much oral is taken in, are they tachycardic, how are
the BP’s?
• Young patients should void at least their kg. wt. an
hour. Older patients should void at least .5cc/kg/hr.
• Frequent and prompt documentation with
evaluation can prevent adverse events.
Bring on the ADLS
Pulse ox site needs to be
changes once per shift.
Pericare is done on pts.
with foleys. If a patient is
incontinent and needs
cleaning, chart “perineum”
care under Hygiene not
pericare.
Difference between:
Menstruation is normal and
vaginal bleeding is abnormal.
Drop-down box for vaginal
bleeding has descriptions for
the flow: clotted, scant,
moderate, and heavy.
Students should notify nurse/CP so the
issue can be addressed later in the shift.
Students should document
ambulating patients by
duration in time and can
annotate how many times
around the unit.
Infants also need documentation
of activities or repositioning q 2
hrs. If activity or repositioning is
not documented, then it looks
like the infant has remained in
his crib all shift without
movement.
Nutrition by Nursing
Challenges with Nutrition
• Some parents order more food that normal because
child has been picky and parents are trying to get
them to eat something.
• Some order more to share with the patient.
• Pediatric patients order from room service whereas
adults have standard trays.
• Most precise way to evaluate nutrition status would
be to chart the total of only the foods that the
patient tried to eat.
Summary
• Charting is a form of communication between
staff. Charting helps us to document our
patients progress and need for treatment.
Therefore, accuracy is essential for safe,
quality care and should be a joint effort
between students, instructors, and staff.