Nurses on the front line are often challenged to document each individual dose adjustment of complicated medication titrations while simultaneously providing emergent/urgent care to patients. With feedback from those providing care, The Joint Commission (TJC) changed and clarified the documentation requirements for certain titration orders during emergency/urgent medical situations in intensive care units (ICU) or procedural areas. The guidance provides the option of “block charting” as a documentation method during urgent or emergent situations. Block charting may save nurses valuable time when seconds matter most but requires advance preparation. Here’s an overview of the guidance as well as some considerations as you determine if block charting is right for your hospital.
What is block charting for titrated medications?
Simply put, block charting is providing documentation in four-hour time periods. It may only be used for an emergent/urgent situation as defined by your organization’s policy and is restricted for use in critical and procedural areas such as during an unstable hemodynamic event in the ICU. Each block is limited to four hours (a new block must be started if it goes beyond four hours) and should include the following documentation in the medical record:
- Start and end times for the block charting episode
- Complete and accurate order for each medication for titration
- Start and end rate/dose during the block charting episode
- Maximum rate/dose
- Objective parameters used to make decisions about titrated medications
Does a block charting process have to be included in a policy?
Yes. Organization policies are often the foundation for standardizing practice. A well written policy usually provides definition(s), rationale and step(s) for the process. It also includes guidelines based on regulatory requirements and references. If you want to begin a block charting process, TJC requires the following minimal elements to be documented in a policy:
- Identify the emergency/urgent situations where block charting is allowed by your organization
- Outline what must be included in the documentation (tips above)
- Define which staff can use block charting and competency requirements for staff using block charting
Note: If a policy allows the clinician administering the medication to select which medications to administer based on specific criteria (from a list of ordered medications), that clinician must have documented competency to do so.
When is block charting prohibited?
There are always rules to follow when documenting medication administration. Similarly, regulatory ‘thou shall nots’ of block charting exist, and the following are not allowed:
- Non-emergency/non-urgent medical situations
- Situations outside the ICU/procedural areas
- If a complete and accurate order is not present for each medication for titration
- When there is no policy to support the process or the policy prohibits block charting
Suggestions for successful implementation
Developing a successful block charting process will require detailed attention by a multidisciplinary team of intensivists, nurses and pharmacists to ensure adherence to the regulations. Once the block charting policy has been developed and approved per your organization’s internal process, it’s critical to ensure that staff from ICU and any other procedural areas where block charting would apply, are educated regarding the policy. In addition, ensuring that medical records are audited for completeness and compliance is an important step for any successful change to documentation workflow.
Block charting may not be a simple solution, but when all of the parameters are met, it could provide valuable seconds for nurses on the front line in critical care and procedural areas who struggle to meet the rigorous demands of balancing complex care and timely documentation requirements. Additional Information is available from the Joint Commission FAQs.
Vizient provides accreditation services and resources to help hospitals stay on top of the latest health care requirements. To learn more, check out Vizient’s website or email me.
About the author: Marianne Sevcik, RN BSN MSN, is an advisor who provides accreditation and regulatory consultation services to Vizient member organizations. Prior to joining Vizient, Marianne was a Joint Commission Surveyor for five years and has more than 30 years’ experience in health care organizations, including leadership positions that required oversight of regulatory compliance.