Charting/Nurses Notes - page 2

Charting/Nurses Notes Hello everyone, You all helped me so much with my Frequent Faller questions, So I have another question. I have to give an inservice on Charting. I work in a nurseing... Read More

  1. by   nsnan_2000
    Could you please fax me a copy of your alert charting form to try at my facility, and any other documentation inservices you might have. Our facility just went through inspection and our only flags were in documentation and charting. We are having an eight hour nurses meeting on July 2nd and I think it would be extremely helpful. Thank-you so very much. Nancy in Oklahoma
    OUR FAX # 580-924-1302 Attn: Nancy Harris






    Quote from zuchRN
    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
  2. by   marycd
    Quote from StormyCD
    Charting/Nurses Notes

    Hello everyone, You all helped me so much with my Frequent Faller questions, So I have another question.

    I have to give an inservice on Charting. I work in a nurseing home and the charting can, at times, be very minimal and often confusing. Does any one have some hints for the inservice? Or does anyone know where I might find information on the internet?? I'd like to teach my co-workers to chart more detailed information, knowing that this may save lots of problems in the future...thanks in advance...

    StormyCD
    Not sure if this is where i need to put my reply/Qestion
    After being away from nursing for 7 years, i need help with charting.
    working in LTC on skilled medicare floor. It seems very busy and disorganized.
    i suppose i should go to inservice coordinator and get help. but what information can you give me. thanks, Mary
  3. by   dd_txlvn
    Quote from zuchRN
    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
    I know I am a little late, but I am needing to do and inservice on Medicare Charting--do you mind faxing or emailing me any info??
    Fax # 817-444-8432 or email to dbunker@burmont.com
  4. by   lisagw
    Quote from zuchRN
    At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.
    I also have the same problem. Could you email me a copy of your forms as well?
  5. by   geriRN1993
    Quote from marycd
    Not sure if this is where i need to put my reply/Qestion
    After being away from nursing for 7 years, i need help with charting.
    working in LTC on skilled medicare floor. It seems very busy and disorganized.
    i suppose i should go to inservice coordinator and get help. but what information can you give me. thanks, Mary
    Medicare charting is so very important to the reimbursement of the facility that it be correct. What I teach and prefer is a written nurse's note not a form because it allows the nurse to give much more information. Start with the standard head to toe assessment, concentrating on the system that the patient has areas of trouble (ex. breath sounds. O2 sat, and presence of shortness of breath for a pneumonia). All Medicare charting should also include "why they require skilled care" example: currently receiving therapies OT or PT due to the weakness developed from the pneumonia or ambulation issues due to a hip fracture or IV therapy due to infection. The key to all the charting is to "know" your resident. Know why they are in your facility. Have a general idea of their other diagnoses.
  6. by   dian57
    I also have inserviced staff on LTC documentation. I can send you my Tips on Documentation sheet that is posted on all units. Email me.

    An important thing for new nurses to understand is the importance of reading the previous two entries in a chart before putting pen to paper. I was surprised when I went back to school for my RN that this was never mentioned during our 1 class on documentation (no wonder new nurses have trouble charting accurately and quickly).

    How many times do you cringe when reading two conflicting notes following one another? Or the 'necrotic' area on 7-3 becomes 'discolored' or 'abraded' on 3-11 and then no mention at all on 11-7.
  7. by   Jdon
    Quote from brown eyes
    this is brown eyes my fax number is 3178941073 and i will do the same thank you very much
    Brown eyes
    Sorry to say i am no longer at my previous job. I hope you did'nt fax anything there, because i would'nt have got it. Sorry for the inconveinence.
  8. by   Chel
    Quote from dotty865
    Hi , I was wondering about charting also. But my question is ... How many LTC facilities are using computers for charting ? In fact do hospitals use computers for charting ? I was told by my DON that it is coming soon to our facility . I think this would be better. There is always someone that wants the chart at the same that that I need it to do my charting . What does everyone think about this ?
    Mine doesn't...and probably never will. One of my clinical sites used computers for charting. Soooo much easier. Everything was right there.

    Last night one of the nurses had to find a couple of labs in a hurry r/t a panic level pt/inr we were getting stat labs on for a few days (doctor was on the phone). They were no where to be found. She was embarrassed in front of the doctor, and felt like a total idiot expecting things to be were they could be found. She never found the labs, but I have a habit of keeping a pad of nurses notes beside me. Everything that goes on gets written there, or when I have to jot down numbers, names, critical labs, etc...just so I remember to see to it. It was still in the shred drawer ~ lab values and all. If we had computers we wouldn't have had to waste 30 minutes looking for them.

    Hmmm ~ maybe I'll just put that in the suggestion box.
  9. by   texastea
    Just looking through old post and saw this one about charting and documentation. If you could e-mail me anything you can spare I could use all the help I can get they just took 12,000 back from us due to poor charting.
  10. by   sissie43
    I am like 4668 i was looking around at some of the threads and i could use some help with information on charting. Anything on restorative documentation. My fax is 325-643-4169 thanks

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