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Documentation vs. Patient Care Flowsheet Eases Multiple Demands

by Cynthia Kadziulis, RN, BC, ALNC, CLNC

Working in an acute Behavioral Health and Addiction setting has many challenges. As nurses we’re stretched to get our meds out on time, make contact with our patients, provide the one-on-one time needed, and hold therapeutic groups. We worry about maintaining safety, preventing outbursts and having the time to deescalate a situation versus utilizing chemical restraint. We dread the thought of a fall or having to place someone in mechanical restraints.

The medical acuity of our patients has increased over the years. We have IVs, foleys, wound care and PIC lines. We have more geriatric patients than ever before. Our patients’ suicide attempts are more severe and the consumption of alcohol and overdose is at an all-time high. We make every attempt to meet the needs of our patients, but what do we do when we’re pressed for time and documentation is also a priority? If documentation is not done, how will the psychiatrists and physicians know what was effective?

The psychiatrists and physicians utilize what we have recorded to help plan their next course of treatment. We often find ourselves in a dilemma of not having the time to register the measures we’ve taken for periods of anxiety, agitation, increased hallucinations, detox and withdrawal symptoms. Those periods of documentation are generally reserved for the patient that we weren’t able to deescalate or stabilize medically.

Joint Commission requires us to document why we administered a PRN. They want to know what non-pharmacologic interventions we’ve attempted and what our next steps were. They want to see what medications were given and whether they were effective. More often than not, I’ve seen that although one attempts to be diligent in documenting, the reassessment is left out, whatever the reason.

In dealing with these challenges on a day-to-day basis, I took the opportunity to develop a unit specific flowsheet for the Behavioral Health and Addictions setting. By utilizing this form, the nurses now have easier access to document the initial behavior, non-pharmacologic interventions, medication provided and the effectiveness of all therapies used at the time of application. No longer does the psychiatrist or physician need to hunt through the progress notes to see which PRN medication was administered and determine whether it was effective.

The purpose of this flowsheet is to have a more consistent way of documenting assessment and reassessment of symptom levels using our universal 0/10 scale. On this form one is able to chart initial assessment levels, the non-pharmacologic interventions exercised and the effectiveness of both or either, all on the same line.

By implementing this form, nursing, medical and utilization review are able to track the effectiveness of our PRN medications as well as the alternative interventions used in a more cost effective and well-organized approach. At a glance, medical staff is able to assess whether the PRN medications prescribed are effective, and to what degree, in treating each individual. Because the psychiatrists and physicians are more informed, they are better equipped to make the needed adjustments in medication management for each individual. This can ultimately result in improved medication compliance for the patient.

Joint Commission is able to clearly and quickly ascertain that the documentation of assessment and reassessment is being done in a consistent and efficient manner.

There is no further need to chart PRNs administered in the progress notes. This type of charting is not only redundant but time consuming, pulling the nurse away from time that could have been spent doing patient care. Now, the only time a progress note would be warranted for a PRN medication would be that of “exception.” For example, something that would obligate further explanation – such as the administration of an IM injection and the behaviors leading up to it – could not be explained in your comment box.

Behaviors most frequently employed on this form are anxiety, agitation, hallucinations and delusions. The “other” section is for additional PRNs administered for things such as insomnia, nausea, elevated detox scores, etc. Non-Pharmacologic interventions are also documented on this flowsheet as well as the date, time and initials of each nurse completing the assessment and re-assessment. The entire documented entry is completed on one line.

Shift to shift documentation for reassessments is no longer an issue. The flowsheet is kept in the medication administration record, and due to the easy read, each new shift coming on can easily see when reassessment is due.

Not only has implementing this form proven to be a productive way in documentation, there is also improved compliance with Joint Commission regarding reassessments. Nursing is able to be utilized more efficiently, and as a result, it has the magnitude of placing one’s institution in a status for improved financial capacity.