I work in a large CBRF as a unit coordinator and am really frustrated with the floor nurses' charting. Its not all of the nurses, but most of them. They just don't chart or don't want to chart on a sick resident longer than 24hrs. I just don't get it. Maybe its the SNF nurse in me but, If the resident is sick, they should be assessed and charted on. Example..... it will be written on the report board that so-n-so has sore red area under abd fold or cold s/s, but NOTHING in the chart. IF there is something charted it is very generic. Example... "scrape to resident's leg looks infected. Hospice updated." Ummmmm..... what happened to describing HOW it appears infected? It makes it really hard to come in and know what happened over the weekend or even over night. When I ask the worst offenders, their response is always "This is a CBRF NOT a SNF. We don't do that."
So, my question(s) is this...
For those that have more experience than I in CBRF/AL - is this really the norm for charting?
How do you chart on your residents?
Do you have set guidelines on what needs to be charted and what doesn't? I've actually had a couple nurses (very seasoned nurses) ask for this. I feel its common nursing knowledge.
Do you chart on the progress of wounds on a regular basis or just initially?
Do you chart names (other than the MD's) in the nurses notes?
I know these sound like very silly questions, but this is truly what I am faced with. I was taught in nursing school that charting needed to be detailed. And if its not charted it's not done. I am actually to the point of asking my boss for a mandatory charting inservice.We can review and review these things in our nurses meeting, but they just don't get it!
Any and all advice is GREATLY appreciated!