Where is the charting????

  1. I am in first semester clinicals in LTC. I am disturbed by the fact that at the facility I am at there is very little charting done! We are there one day a week and the only charting of vital signs and patient care outside of ordered treatments is being done by us.. the students. By this I mean there is a treatment/med book that things such as G-tube flushes, dressing changes and meds are signed off on. There is however maybe once every few months an entry in the patient's charts of vital signs, I/O, BMs etc. For instance, today a fellow student who was told his patient was constipated looked in the chart for date of last BM and found the last BM recorded was 3 months ago!

    Is this normal? Is this ok?
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  2. 6 Comments

  3. by   ALT
    Wow That's um..not normal at least here where I am. Charting is done daily. Even when I was just a CNA I had to chart all that stuff or I would get my butt handed to me on a tray. I personally think the CNA's there are falling down on the job and the administration is letting them get by with it. My only question is how does this facility get paid for their services. Insurance companies Medicare included are wanting to see the charting so they know exactly what's going on.
  4. by   GratefulHeart
    Quote from OnTheRoad
    I am in first semester clinicals in LTC. I am disturbed by the fact that at the facility I am at there is very little charting done! We are there one day a week and the only charting of vital signs and patient care outside of ordered treatments is being done by us.. the students. By this I mean there is a treatment/med book that things such as G-tube flushes, dressing changes and meds are signed off on. There is however maybe once every few months an entry in the patient's charts of vital signs, I/O, BMs etc. For instance, today a fellow student who was told his patient was constipated looked in the chart for date of last BM and found the last BM recorded was 3 months ago!

    Is this normal? Is this ok?
    What does your instructor say about this? Just curious.
  5. by   OnTheRoad
    Quote from ALT
    My only question is how does this facility get paid for their services. Insurance companies Medicare included are wanting to see the charting so they know exactly what's going on.
    I was wondering about what they (medicare/medicaid etc) thinks about the lack of charting. They do get paid through medicare/ medicaid/ private pay etc. We haven't covered legal issues in nursing yet (beyond Hippa, and what WE students need to do legally and ethically in our clinicals), but I just didn't think this seemed normal.
  6. by   OnTheRoad
    Quote from GratefulHeart
    What does your instructor say about this? Just curious.
    I haven't asked pointedly about the situation, but we have mentioned repeatedly that we are the only ones doing this type of charting and she seems to be frustrated (with the facility, not us). I probably should ask her pointedly about it.
  7. by   Daytonite
    Most of the LTCs I worked in had charting forms that the CNAs filled out also. On them, BMs were addressed. Did you check these? Many times these forms don't even make it into the chartbacks. They often go directly to the person who does the filing and are filed in the patient's overflow chart in the records area. When I wanted to check on BMs I went to these CNA forms which were kept in 3-ring binders at the nursing station. Our assistant DON was specifically assigned to check those CNA sheets for completeness, particularly for BMs. It's one of the first things the state looks for when they come inspecting.
  8. by   OnTheRoad
    Thanks daytonite! I will ask about the overflow files because I know this stuff was nowhere in the chart. It would make sense to have it somewhere else seeing as how big the chart is without these daily things in it

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