My unit is a 36 bed psychiatric unit taking ages ranging from 18 years and up with a variety of psychiatric disorders. Our patient's have a variety of co-morbidities but usually come to our unit "medically stable." Currently we are charting a head to toe physical assessment twice a day, a mental status nursing note twice a day, plus other charting like education, fall risk, IPOC, delirium assessment, pain assessment, braden, and on the early warning system (EWSS). All this charting takes nursing's time away from the bedside with patients. I am wanting to decrease the amount of charting nursing is required to do.
For those of you that work on units similar to mine, how often are you charting on the patients and what are you chartings?
I appreciate any information you can provide!
Tamsyn