As a night shift nurse, I agree charting can get monotonous. I am requires to chart on anyone on medicare, abx, new admits, hospital returns and more.
1: For skilled residents, my typical note would have VS if taken, followed by "resting in bed with eyes closed all night, no c/o (or s/s of) pain, discomfort (resp distress if appropriate)". I would also add any behavior or change (in continence, sleep pattern, condition, ect.). I've charted this so many times I feel like a broken record but have never been called out for this.
2: As a LPN, I do chart rhonchi, rales, wheezes, diminished for lung sounds if I am sure of what I am hearing. We have been inserviced on the new MDS 3.0, but not on any differences in charting. There has been yet another piece of paperwork we must fill in on each resident every shift regarding "pain" as a result of the MDS 3.0. Any more paperwork and I'll have NO TIME for patient care!!
3: Yes, we do chart on falls in addition to the incident report. The incident report is much more detailed. The chart might read something like "found on floor at bedside @ 0100, stated "I slid trying to get up to go to the bathroom", denies hitting head, denies pain, VS..., skin tear on L anterior forearm 2 cm x 0.5 cm, (whoever you notify) notified @ 0115."
As for LVN/RN charting, chart what you do, the RN charts what they do. If I notice a change in condition, I chart what I observed, VS, ect then "reported to RN supervisor". The RN makes the decision to call the doc or 911 and makes the call. The RN then charts what they did, ie: "called Dr. B @ 0200, verbal orders to send to X hospital, left via XYZ ambulance @ 0230, (name of POA) notified @ 0235." Notes are usually much more detailed, but hopefully it gives you an idea of the difference.
Hope this helps!