I'm a LVN (in TX) that has worked in acute care for a few years. I've recently went to work at a LTC facility in order to finish up my RN. There are a couple of issues I'm confused about and anytime I try to look them up online I get lost in all the websites. I've been work in LTC for about 8 months now and am still a little puzzled about a few things. Any help would be greatly appreciated.
1. Skilled residents - Legally, how many time per day do they have to be charted on? I don't have any problems with people that are on anti-biotics and such but charting on the skilled ones at night is crazy to me. It's starts getting old after the 45th day of 100.
2. MDS 3.0 - We were told our charting needs to change for the MDS 3.0. I don't really understand what that mean. We were also told not to chart Resp even/unlabored but to chart Rhonci, Wheezing, Rales etc. Now as a LVN am I legally able to chart breath sounds? I was under the impression only RN's/Dr. could chart that. I've always used adventious breath sounds. They were want more of times to BSC and things like that but also more charting on residents moods and things like that. I work night shift so it's hard to assess somethings. I guess I just need a basic template of things to cover in my charting.
3. Falls - At the facility I work at they want us to actually chart in the chart if someone falls. Isn't the incident report itself it's "own chart" I know at the hospital we weren't allowed to do that.
3. RN/LVN Charting - can someone lead me in the right direction where I may be able to find some information stating the difference in charting between RN and LVN. I know it's not the same in the hospital setting but didn't know how different it is in LTC.