9.17: Flow Sheet
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.
