CCTC Graphic Record Revisions Introduce new graphic record Provides more area for charting routine interventions Complements the soon-to-be revised AI record Provides the basis for EPR Define documentation standards Documentation standards define the ruler used to measure practice Knowledge of standards essential Standards of Nursing Care can be found on CCTC website under “Standards”
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CCTC Graphic Record Revisions - lhsc.on.ca Graphic Record Revisions 9Introduce new graphic record Provides more area for charting routine interventions ... oxygen delivery (need to
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CCTC Graphic Record RevisionsIntroduce new graphic record
Provides more area for charting routine interventionsComplements the soon-to-be revised AI recordProvides the basis for EPR
Define documentation standardsDocumentation standards define the ruler used to measure practiceKnowledge of standards essentialStandards of Nursing Care can be found on CCTC website under “Standards”
CCTC Graphic RecordOn AI record, a “tick” means within normal limitArrow over if everything is the same as last chartingIf findings are outside normal limits, you must “Star” and “DAR” in the AI recordRemember to chart responses to interventionsREMEMBER TO INITIAL at the bottom of each column when data is entered
CCTC Graphic RecordIf you carry out an intervention by “prn” option (e.g., measure a blood gas), you are required to document the reason
Failure to document rationale is equal to carrying out a medical act without an order
If you chart that you will “Monitor electrolytes and treat per PPO” on the 0700 hrs Assessment Record, you don’t need to chart why you gave a potassium bolus and repeated the lytesIf you measured lytes due to an arrhythmia, this is outside the PPO and requires a reason documented
CCTC Graphic RecordRemember to document the response to an intervention
Failure to document response indicates pre-existing problem is still present (e.g., if charting indicates SpO2 has decreased and FiO2was increased, failure to chart the response indicates the patient still has a low SpO2)“Arrow over” means everything is the same as charted in the last notationDo not arrow over from a “Star” and DAR” for a one time event (e.g., family meeting, dressing change)
Neuro Page
• Chart all labs and diagnostic tests
• Chart transfers in and out
STANDARD:• Must document in AI record reason labs are
drawn if by “prn” protocol
• Labs not included in preprinted protocols require an order (e.g., cardiac enzymes, liver enzymes, cultures)
Neuro Page
• ICP, CPP, zero/level and SjO2 moved to neuro section
• Add Train of Four here is needed
STANDARD:• Chart hourly if ICP in place
• Calculate CPP
T.O.F. 2/4
Neuro Page
• Neuro definitions simplified
• Link scores to create graph
STANDARD:• Document q shift for all patients
• Document q 1 h for all acute neuro
• Document q 1-4 h for stable neuro
Neuro Page
• Chart pupil size after adjustment to ambient room light
• Continue to use previous codes:
Brisk
= Fixed
- Sluggish
STANDARD:• Monitor and chart q1h and prn for
patients with neurological injury.
• Pressure on 3rd cranial nerve causes loss of ability to constrict on the side of the lesion (or loss of the parasympathetic response). Pupil becomes dilated and non-reactive. 3rd cranial nerve is located at top of brainstem; new finding suggests brainstem compression.
• Sympathetic control of pupil is located in pons; injury here causes loss of ability to dilate (pupil becomes pinpoint and non-reactive).
Neuro Page
• Chart eye opening, verbal and motor response.
• Total each score.
• Trend important.
STANDARD:• Chart q shift for all patients
• Chart q1-4h for all patients with neurological alteration
• Chart BEST response; GCS is an assessment of the BEST cerebral function not symmetry
• Provide best estimate of verbal response.
•If intubated patient able to write or communicate appropriately, give a 5 (or 4).
• Do not mark “T” unless the patient could be better.
Steven is a 26 year old who sustained a head injury. He opens his eyes to pain only, is intubated and plays with his foley catheter with his right hand.
He has abnormal posturing with his left arm and no movement in his legs.
What is his GCS?
Eye Verbal Motor6 obeys
5 oriented 5 localizes
4 spontaneous 4 confused 4 withdraws
3 voice 3 inappropriate 3 flexion
2 pain 2 incomprehensible 2 extension
1 none 1 none 1 none
4 5 6
Because he is not communicating, his verbal score is “1”. If you think he might be able to make verbal sounds if extubated, you can give him a 1T (total score 8T) to indicate he is at least an 8, possibly higher.
Tom has a C3 cord injury. He opens his eyes spontaneously, is ventilated, has flaccid paralysis X 4 and blinks to
command.
Eye Verbal Motor6 obeys
5 oriented 5 localizes
4 spontaneous 4 confused 4 withdraws
3 voice 3 inappropriate 3 flexion
2 pain 2 incomprehensible 2 extension
1 none 1 none 1 none
4 5 6His inability to move is not related to his brain. GCS identifies his best cerebral function. Within the limits of his cord injury and ETT, he is able to obey and communicate. His score is 15. DO NOT add a “T” to his verbal or total score, as you have already given the highest verbal score possible. “T” indicates the score could be higher.
Neuro Page
• Identify differences in each limb
STANDARD:• Record L (localizing), W (withdrawal), F (flexion)
or E (extension). “O” means “no movement” (NOT obeying). Can use + or – if localizingbilaterally with obvious weakness.
• If patient obeys, a numerical score using 0-5/5 motor score is required.
• If patient has uncleared CTL spines or is a post-op aneurysm repair, a spinal cord record must be used and chart q1h until clear.
Motor Score5. normal strength (muscle contraction
against resistance)4. mild weakness (weakly against resistance)3. support limb against gravity but not
against examiner’s resistance2. able to move but not against gravity1. flicker but no movement0. no movement
12-hour Vital Signs Pages
Charting of BP, HR and temperature unchanged
• Chart high and low alarm limit settings or “off”
• ExampleECG: 50-130
STANDARD:• ECG and BP alarms are on
and set appropriately
• If you chart “off”, rationale and troubleshooting must be documented in AI record
50-130
12-hour Vital Signs Pages
• Chart SVO2 (drawn from PA tip) or ScvO2 (drawn from right atrial sample drawn from IJ or SC)
STANDARD:• Venous oxygen saturation is measured
to examine adequacy of cardiac output (it is not a pulmonary assessment)
• Measure to evaluate adequacy of CV resuscitation, BP or CV drug support