Dear Practitioner:

I would like to introduce to you a Universal flowsheet system. The new system embodies a more coherent application of policy for the ICU and includes aids to help the nurse and hospital avoid the legal and ethical consequences of not complying with policy. The system achieves this via instructions on the flowsheet itself as well as a set of assessment cards for various problems.

The Universal ICU system was developed based on Guidelines for changing the flowsheet. Please keep in mind that the Universal ICU flowsheet and assessment cards were designed based on the policy at one particular hospital.

As you look over the Universal ICU flowsheet you may have some questions. I hope that the following information will explain some of them.

An infusion line can be connected to a variety of access devices that intrude into the body. Invasive line sites can be venous or arterial. They include the following:

The letter code is used to simplify documentation of what fluid or medication is infusing into which invasive line site. The letter code is defined on the intake portion of pages 2 (day shift) and 3 (night shift). For example: Your patient is being infused with lidocaine. On page 2, one would write "lidocaine" in the box labeled "A." On page 1, one would fill in the invasive line assessment listing the type and location, date of insertion, write "A" in the letter code column, and fill in the blood return and problem blanks as needed.

The boxes are split so that two numbers can be charted. The first number will be the amount of medication and the second number is the amount of volume. At the bottom of the sheet is a list of units of infusion rate. You choose which unit the drug you are using is measured in. For example: Write lidocaine in the box with the letter A in it. Then write X indicating mg/min. In the first part of the split box write 2 and the second part write 30. Lidocaine is running at 2mg/min or 30cc/hr.

A frequent assessment page (page 5) comes in handy when unexpected changes in a patient’s condition occur or when frequent monitoring is needed. A frequent assessment page can also be used to contain instructions on items that would only be used on a short-term basis.

For example:

The Ramsey scale is used to determine the level of sedation. This scale is found on the bottom of the frequent vital sign sheet as a reference when titrating.

Charting by exception is a system of charting where the nurse documents only abnormal findings or deviations from established norms.

The benefits of using charting by exception are that it eliminates repetitive notes which decreases charting time, and it makes changes in a patient’s condition easier to find.

Charting by exception challenges the long held legal belief "if it is not charted then it was not done." And replaces it with a new premise, " all standards have been met with a normal or expected response unless documented otherwise."

The initial assessment is your first assessment of your patient. It comprises a whole body assessment that is divided up into systems. Each system has a definition of what normal is defined as. In this case, normal is conforming to a standard regarded as usual or typical for a healthy adult. For example, the normal heart rate range is from 60 to 100 beats a minute. On page 8 you can find the definition of the cardiovascular system. A normal heart rate and rhythm is part of that assessment. If your patient has a normal heart rate and rhythm then he is within normal limits (WNL). The time of the initial assessment for day shift and night shift is documented on page 1. The invasive line assessment is also found on page 1 and the rest of the whole body assessment is found on the back of the flow sheet. The content of each body system assessment conforms to hospital policy, and directs the nurse to complete a thorough assessment. Document only deviations from normal.

On page 4 you would write initial assessment across the boxes under the hour that you performed it. Each subsequent assessment would be documented by writing check marks or X’s in the hour assessment boxes. Check marks indicate that statue remains unchanged and an X means that there has been a change and an explanation can be found in the nurses notes. A complete assessment is performed every 4 hours. A blank box indicates that no assessment was needed at that time.

If you have questions, please use our contact page.

Sincerely,

Betty Anderson RNC, designer of the Universal ICU flowsheet system.