BEGINNING OF SHIFT: Clock-in, and document who you received report from and the condition of the patient.

● Document the time report was received.

● Document information relayed during report and the name of the individual you received report from, and if another nurse the credentials of the professional giving report.

● If care is being received from a family member or other caregiver, document that person's name and relationship to the patient. Do not document only "Mom" or "Parent care Giver (PCG)."

● Sign with your full name and credentials.

WITHIN 30 MINUTES OF THE START OF YOUR SHIFT:

● Complete and document Temperature, Pulse, Respiration (T,P,R) and any other Vital/Sign as ordered on Plan of Care.

● Document information relayed during report and the name of the individual you received report from, and if another nurse the credentials of the professional giving report.

● Initial patient assessment

● Additional assessment details

● If applicable, ventilator settings are confirmed as correct and document on the Ventilator Log

EVERY HOUR:

● Enteral feed volume

● Intravenous fluid, TPN, or Lipid amounts

● Intravenous access site assessment on the Intravenous Infusion Flow Sheet if an infusion is running.

● 02 saturation, amount of supplemental oxygen being administered.

EVERY TWO HOURS:

● Intake and output

● Turn and reposition

● Ongoing patient assessments, treatment, interventions, medication administered, etc. and responses to treatment and interventions

● If applicable, ventilator settings are re-confirmed and documented on Ventilator Log.

● Assessment of the intravenous access site on the Intravenous Flow Sheet (when no infusion running)

ONGOING AND PRN DURING THE SHIFT:

● All medications (routine, prn, IV) are documented on the MAR as they are administered.

● Reassess the patient and document effectiveness within 60 minutes of the administration of a PRN medication

● Findings of concern- All assessments not consistent with patient's baseline or other concern are documented in the narrative notes, as all as interventions and reassessment as well as notifications related to area of concern.

● Seizure activity, description, interventions, and reassessments are documented on the Seizure Record as they occur.

● All new, changed, or discontinued orders are documented on the Supplemental Physician Orders.

● The Medication Administration Record is updated immediately when orders are received.

● Patient and family education are documented as it occurs.

● Document the topic, who you taught, how long it took, and their understanding.

● Notifications- to supervisor, physician, and/or other providers

● Progress toward goals- there should be documentation during the shift related to patient specific goals.

● Close out notes 30 minutes prior to the end of your shift, stating the condition of your patient and whom you left the patient with care with.

END OF SHIFT:

● The time you leave the home is documented in the "clock out" section. Obtain parent/caregiver signature to confirm that you provided patient care during the time documented. Should be done prior to leaving the home or next shift.

● Cleaning, restocking, and maintenance activities are documented.

● End of shift assessment is documented, document how you left your patient.

● Hand-off Communication to the next care provider is documented as a narrative note in the clock out note.

● Document the time report was given.

● Document information relayed during report, and the name of the individual you gave report to and if another nurse, the credentials of the professional receiving the report.

● If care is being turned over to a family member or other caregiver, document that person's name and relationship to the patient. Do not document only "Mom" or "Parent Care Giver (PCG)."

● Sign with your full name and credentials.

I have read and agree to the documentation requirements policy.