I’ve worked at a few places now, and I’ve, for the most part, loved every minute. I think other nurses will understand when I say that the biggest learning curve is figuring out the different styles, and forms of documentation that different places use. None are necessarily better than others, just different. However, there is one consistent issue I’ve noticed crop up fairly regularly. Fluid balance charts.
For the non-medical readers, this is a balance sheet of what a patient has taken in fluid wise, either through drinks, food, IV therapy etc. This number is then balanced with what has come out of the patient… I’ll leave how to your imagination. This is important because the fluid in a person can impact the whole body, every system within it.
Don’t panic. I’m not going to make this a mini A&P lesson. It’s the documentation side of things I’m focused on at the moment. I’m most likely not going to change the documentation habits of an entire hospital, maybe not even the ward. In a perfect world, I would love to see a uniform protocol and method of documentation across the state. I think a lot of the issue is the lack of uniformity, or enforced methods of measurement, particularly when tallying up incontinent patients. for example, I know some facilities use scales, others do not. It is this kind of inconsistency that makes it difficult for new or itinerant staff members coming into workplaces.
There is something I can do, however. I can make sure I am doing the best fluid balance charts I can for my patients. I know that sometimes a shift can get away from me, and I’m working on changing my own habits when it comes to documentation. So as a nurse wanting to improve personal practice Do any of the nurses out there have any suggestions for maintaining accurate balance charts? Has your hospital/healthcare facility got a protocol in place that has managed to achieve a high level of compliance? Is there anything that you know you’re doing differently that I might be able to try and introduce?