? about forms

  1. Hello,
    I have been reading everyones post about trying to improve your facilities. I know my facility needs a lot of help with documentation and follow thru. I was wondering do you keep I&O sheets on everyone with Foleys or S/P tubes , even if they are long term caths? What about tube feedings? We document I&O's in our notes, if they are skilled or there is something going on, but otherwise we don't have a seperate sheet.
    One nurse told me, " We don't need more paperwork, it's only one more thing for the state to get us on "
    I don't want to be one the nurses that just goes along with everything just because "that's the way we have always done it".

    Thanks,
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  2. 9 Comments

  3. by   caliotter3
    When I worked in LTC, we collected I&O data for the examples you described.
    The data was looked at by the licensed nurses but the original sheets and data were discarded and the info may or more likely may not have made it to appropriate areas of the pts chart or MDS info. The original sheets were discarded after 30 days as I recall. I disagree with what you were told about creating more paperwork (although that is a valid complaint). The pt is being shortchanged when all aspects of his/her medical cond are not addressed by nrsg staff simply b/c they are in a LTC facility and considered "stable" or just b/c some people are lazy. There are ways to compile appropriate nrsg data without making "productions" out of it. And I am not referring to the "fabricate info" method which I have observed both licensed nurses and assistive personnel engage in.

    For that matter: if this info is not being gathered at all, what defense will there be if something tragic happens and the documentation is requested for evidence in a lawsuit? The nurse who complains about the paperwork will be the first to start crying when the papers aren't there to back her up when it matters. It just might happen you know.
  4. by   Schmoo1022
    We have CNA flow sheets with I&O's on them, these are permanent records that are kept in the patients chart. I was wondering if you also had seperate ones that just the nurses document on?
    Is it not enought to just write in your nursing note..tube feeding running at 40cc/hour, total 320cc, plus g-tube flushed with additional 150cc H2o?
  5. by   Talino
    Quote from Schmoo1022
    We have CNA flow sheets with I&O's on them, these are permanent records that are kept in the patients chart. I was wondering if you also had seperate ones that just the nurses document on?
    Is it not enought to just write in your nursing note..tube feeding running at 40cc/hour, total 320cc, plus g-tube flushed with additional 150cc H2o?
    There is no regulation on the format. Since this will be entered each shift on a daily basis, a separate I&O will be more convenient, easier to track, and quicker to add up. Write the actual resident outcome in the nurses notes rather than obscure it w/ numbers.

    A skilled need documentation does not always emphasize a daily narrative nurses note to support skilled services. A stand alone MAR/TAR or I&O sheet is proof itself.
  6. by   Schmoo1022
    Quote from Talino
    There is no regulation on the format. Since this will be entered each shift on a daily basis, a separate I&O will be more convenient, easier to track, and quicker to add up. Write the actual resident outcome in the nurses notes rather than obscure it w/ numbers.

    A skilled need documentation does not always emphasize a daily narrative nurses note to support skilled services. A stand alone MAR/TAR or I&O sheet
    is proof itself.
    Makes sense. Thanks for the replies!
  7. by   withasmilelpn
    The more forms we have the more likely we are to miss one or two. In our facility we have mars, tars, pain, behavioral, mood (yes seperate with about 20 questions in teeny, tiny print), mds adl tracking form, wound tracking sheet, vs,and I&O. We are expected to chart too, and cover the majority of these things again in the chart, each shift. Drives me crazy, as I thought the rationale for flow sheets were to cut down on our charting!
    By the way does anyone know why its necessary to chart how many minutes a patient recieved a nebulizer? They just started that. Also we have to rechart all the BMs on are MARS,although the CNAs do as well on theur paperwork. There are often tons of 'holes', places where people have not filled out their paperwork. Also drives me crazy, makes the facility look bad. Now to help out the unit manager we have put people on antibiotics on a tracking sheet for infectious control purposes. We have to count our narcotics twice, once by individual patients sheet, and again by a total unit count. Don't forget all the pt teaching sheets and immunization sheets!Sometimes I think I'll go completely over the edge if they introduce one more sheet of paper for me to fill out.
  8. by   withasmilelpn
    Sorry to be so cynical above, but it does seem as if I&O is one of the ones least likely to be filled out, and I"ve been to a quite a few places,
  9. by   Schmoo1022
    No, your not being cynical. We have so many holes on our sheets too. I want to improve our paperwork and charting and stop writing the same things over and over.
  10. by   withasmilelpn
    Good luck! Let us know how that goes.
  11. by   Schmoo1022
    LOL...Like that will ever happen!! It seems like the paperwork is out of control!!

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