Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.

Here's a closer look at the examples of flowsheets commonly used by nurses:

Graphic Sheet Documentation:

  • Graphic sheets record patient variables such as vital signs (e.g., temperature, blood pressure, pulse rate, respiratory rate) or daily weights.
  • This format presents the data in a graphical or tabular format, allowing for easy visualization and trend analysis of patient parameters over time.

24-Hour Fluid Balance Format:

  • A 24-hour fluid balance flowsheet documents and tracks a patient's fluid intake and output over 24 hours.
  • It includes details such as oral intake, intravenous fluids, urine output, and other fluid losses (e.g., from drains or wound exudate).
  • Maintaining accurate fluid balance records is crucial for assessing hydration status, monitoring fluid therapy effectiveness, and identifying fluid imbalances.

Medication Record:

  • The medication record flowsheet contains precise details of all medications administered to the patient.
  • It includes information such as the date, time, dose, route of administration, medication name, and the nurse's signature.
  • Accurate medication documentation ensures patient safety, tracks medication administration compliance, and prevents medication errors.

Acuity Charting System:

  • The acuity charting system involves documenting patient care activities and assigning acuity scores based on the patient's characteristics and the level of care required.
  • Acuity scores typically range from 1 to 4, with higher scores indicating higher care needs.
  • Each patient is graded according to the level of nursing interventions they need, from "stable patient" to "moderate-risk patient" to "complex patient" to "high-risk patient."
  • For instance, a patient who underwent surgery and requires continuous care has an acuity score of 3. In contrast, a patient awaiting discharge after recovery has an acuity score of 1.
  • These scores help healthcare organizations determine appropriate staffing levels and allocate care resources effectively to meet the needs of specific patient populations.

In summary, flowsheets provide a structured and organized method for documenting various aspects of patient care, including vital signs, fluid balance, medication administration, and care acuity. By utilizing these flowsheet formats, nurses can efficiently track and monitor patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate documentation of patient care activities.

Tags
FlowsheetsNursing DocumentationPatient AssessmentsGraphic Sheet DocumentationVital SignsFluid BalanceMedication RecordAcuity Charting SystemPatient Care ActivitiesFluid Intake And OutputMedication AdministrationHydration StatusPatient SafetyAcuity Scores

Del capítulo 9:

article

Now Playing

9.17 : Flow Sheet

Documentation and Reporting

1.1K Vistas

article

9.1 : Introducción a la Documentación y la Presentación de Informes

Documentation and Reporting

1.1K Vistas

article

9.2 : Propósito de las Historias Clínicas I

Documentation and Reporting

879 Vistas

article

9.3 : Finalidad de las Historias Clínicas II

Documentation and Reporting

729 Vistas

article

9.4 : Directrices para la Documentación de Enfermería I

Documentation and Reporting

767 Vistas

article

9.5 : Directrices para la Documentación de Enfermería II

Documentation and Reporting

778 Vistas

article

9.6 : Tipos de Registros I: Registros de Unidad y Enfermeras

Documentation and Reporting

844 Vistas

article

9.7 : Tipos de Registros II: Registros Educativos y Administrativos

Documentation and Reporting

674 Vistas

article

9.8 : Métodos de Documentación I: Registros Orientados a la Fuente

Documentation and Reporting

884 Vistas

article

9.9 : Métodos de Documentación II: POMR

Documentation and Reporting

760 Vistas

article

9.10 : Métodos de Documentación III: PIE

Documentation and Reporting

1.0K Vistas

article

9.11 : Métodos de Documentación IV: Gráficos de Enfoque

Documentation and Reporting

782 Vistas

article

9.12 : Métodos de Documentación V: CBE

Documentation and Reporting

645 Vistas

article

9.13 : Métodos de Documentación VI: Modelo de Gestión de Casos

Documentation and Reporting

506 Vistas

article

9.14 : Métodos de Documentación VII: EMR

Documentation and Reporting

618 Vistas

See More

JoVE Logo

Privacidad

Condiciones de uso

Políticas

Investigación

Educación

ACERCA DE JoVE

Copyright © 2025 MyJoVE Corporation. Todos los derechos reservados