Assessment question? Is this common?

[tsm007]

Okay, I am a brand new nurse in a skilled nursing home. I am trying to do my skilled assessments so I tend to look back at other nurses charting for ideas on wording and to figure out patient's baselines. Well, I am noticing a trend. I have one patient that has had a stroke, right sided paralysis, and weakness on the right side. He is in a wheelchair. He needs 1-2 people to transfer (depending on how much he wants to help that day). So anyways I'm reviewing his assessments and most of the nursing assessments have normal marked for ALL extremities on their neurologic assessment. Even the admission one has normal. Well of course now there's a memo from management on my assessment that says "Is the weakness new? Doctor notified. Monitor and document on"

Am I wrong? Should I be charting this as normal? I am not the only nurse that has charted this as weakness, but most nurses chart this as normal. I am seriously seeing most everybody charting everything as normal and just putting in vitals (unless there's something new that's wrong). I don't feel like tackling everyone else's problems, but I want to do the job right. Should I be charting this as normal if this is normal for the resident?

[tsm007]

Ugh and pedal pulses normal on a right below knee amputation! Yes, how is that? Finding this whole charting thing very annoying.

[THELIVINGWORST, ASN, RN]

No. YOU chart what YOU find.

[thenightnurse456]

You're charting YOUR assessment. Don't read back at how others have done it.

[tsm007]

You're charting YOUR assessment. Don't read back at how others have done it.

Well, how else do you determine what someone's baseline is? I haven't looked at it unless I find an abnormal and it's just to determine whether this is new onset or a change from baseline. I'm really frustrated though because with people just charting normal for everything it's harder to tell. I can tell from the admitting diagnosis that these are chronic conditions thus far.

I haven't been looking at others charting to determine what to chart. I was just looking for what the patient's baselines were. Is there another place to look for baselines besides assessment reviews?

I hadn't looked back until I saw a memo from management asking about whether the weakness was new onset.

[ktwlpn, LPN]

Well, how else do you determine what someone's baseline is? I haven't looked at it unless I find an abnormal and it's just to determine whether this is new onset or a change from baseline. I'm really frustrated though because with people just charting normal for everything it's harder to tell. I can tell from the admitting diagnosis that these are chronic conditions thus far.

I haven't been looking at others charting to determine what to chart. I was just looking for what the patient's baselines were. Is there another place to look for baselines besides assessment reviews?

I hadn't looked back until I saw a memo from management asking about whether the weakness was new onset.

Concentrate on the diagnosis,history and physical and take the info straight to management.They have a big problem with documentation,not you....I have seen a number of staff have to go in charts and their document errors...It's fun when a resident falls,sustains a head injury and a pupil is non-reactive......Upon return from the ER after the head CT the family says"her eye has been like that for years,ever since her cataract surgery"...Not noted on the admission assessment......

[hppygr8ful, ASN, RN, EMT-I]

Ugh and pedal pulses normal on a right below knee amputation! Yes, how is that? Finding this whole charting thing very annoying.

Ha Ha Ha Ha - I had a new grad who was full of herself with her bright shiny new license - chart pedal pulses and edema on a double below the knee amputation. Since I was orienting her I asked her to show me where she took the pulses as I had never been able to get pedal pulses on the patient. We went together to the room and pulled up the sheet - oops no feet!

[hppygr8ful, ASN, RN, EMT-I]

Well, how else do you determine what someone's baseline is? I haven't looked at it unless I find an abnormal and it's just to determine whether this is new onset or a change from baseline. I'm really frustrated though because with people just charting normal for everything it's harder to tell. I can tell from the admitting diagnosis that these are chronic conditions thus far.

I haven't been looking at others charting to determine what to chart. I was just looking for what the patient's baselines were. Is there another place to look for baselines besides assessment reviews?

I hadn't looked back until I saw a memo from management asking about whether the weakness was new onset.

You chart your assessment - not what others have charted in the past - Medicare has very specific information they want charted. If you have PCC you do the daily focus charting and add your blurb.

Medicare wants to know orientation, ability to participate in treatment, functional mobility, skin integrity, and nutritional status. Always best to state the facts as you see them in assessment - If you are charting weekness and others are not it should be addressed bi training and in service.

Hppy

[KelRN215, BSN, RN]

Your colleagues are not actually assessing the patients. Let management take that up with them. You chart your findings. If the patient really did develop a new hemiparesis, of course that's something you'd need to call about.

[Jensmom7, BSN, RN]

If there is a place where you can add narrative notation on an admit assessment, I would check the abnormals and then say " _______ present since CVA ______ years ago."

Remember, what you are documenting is what YOU see, it's not just supposed to parrot what someone before you saw (or didn't see). Continue to document in your daily charting, and note any changes from what is now the patient's baseline; i.e. increased contracture, foot drop, whatever.

I'm Hospice, so my focus of charting is on decline, not improvement, but the theory is the same.

[tsm007]

Thank you all so much. I feel like I have learned so much. I have been very insecure in my assessment abilities, but I'm realizing I'm doing better than I thought. Second and perhaps even bigger thing I have learned is I am going to be even more thorough in my assessments and more detailed in my charting. I will try to put detailed notes on my charting about any abnormals being chronic or new so that anyone reviewing the chart will be aware that these are "normal" abnormals for the patient.

[Adele_Michal7, ASN, RN]

Ha Ha Ha Ha - I had a new grad who was full of herself with her bright shiny new license - chart pedal pulses and edema on a double below the knee amputation. Since I was orienting her I asked her to show me where she took the pulses as I had never been able to get pedal pulses on the patient. We went together to the room and pulled up the sheet - oops no feet!

Omg! What did she say?!