Part two of my documentation recommendation for NICU nurses to not chart too

Part two of my documentation recommendation for NICU nurses to not chart too much or too little So first we've talked about charting by exception Now we're going to talk about knowing your policy for documentation Something that really stuck out to me during the Lindsay Clancy trial with Megan Collins is when she was talking about the chest tubes You should have a specific policy that says how frequently you should be documenting your chest tubes and what it is Same with your fluids Same with your central lines Same with your temperature If you read the standard of care for temperature regulation in any ICU, again, adults, peeds, Nicu It says, anytime you're altering the environment that the baby, person, adult, whatever is in, you have to document it hourly Do you know that that means servo mode or skin mode on an incubator or an open warmer? And that's because the bed can warm up or cool down depending what the baby needs and it is in constant fluctuation The baby's not in an open crib We're not altering their temperature when they're in open cribs We don't need to document that hourly But when you're on skin servo mode it is supposed to be documented hourly That's an example of knowing your policy Where I worked as a nurse educator Thank God I had a co-educator that was more of a visual putter together because we all know that's not my biggest strength in case you've ever seen any of my graphs And we made like a basic handout you could have at the bedside And remember the paper form of anything may not be the most current thing But it said this is what you document hourly This is what you document with your cares This is what you The end of the shift and it kind of laid it out for you so you knew The same thing about the temperature's true for blood pressure If you are giving a medication that's altering the baby's blood pressure whether you have an arterial line or not you have to document that much more frequently than with your cares That makes sense So that's the same thing with temperature So in summary my point number two is you've got to know your policy If you know your policies inside and out which should be a huge part of your orientation then you're going to do okay And if you haven't done something for a while so cooling is a big one right? Therapeutic hypothermia If you haven't done that for a while look at your policy Find out how often you need to be documenting all the temperatures You're probably having multiple temperature sources which I still don't know if I agree with but that's usually how it goes Know how often you have to document that Remember, know where your policies are Know how to get there Know your login Know how to search because if something's printed off like you got an orientation and here you are a year later, now you're doing a cooling baby, it may not be the most up to date So, the printed version may not be the most up to date but my second most important thing about documentation is to know your policy