documenting

[DDdove, LPN]

I am confused on what to document on. I know I document PRN meds such as pain, ATB but do I document in nurses notes a nightly assessment such as "Pt sleeping throught out night with no complaints. 0600 meds passed, no compaints or needs stated." I heard you assessed pt every shift for medicare but what if there is nothing happening? And if barrier cream is applied at night by CNA do we document "barrier cream applied"? Another is if the client wanders out of their room at night and then goes back to bed do you say "resident wandering, self redirected back to bed"? or not even document it. I feel so stupid.

[brownbook]

Don't feel stupid. Baring computer charting (which I have not used, and it doesn't sound like you use) you ask 10 nurses what, how, to chart one specific assessment and you will get 15 answers!!!

Read over what other nurses in your institution chart. Find what sounds right for you. Read your facilities policy and procedure manuals about charting.

Most charting issues are how will my charting sound in a court of law.

"Pt. sleeping," is a big no no. The lawyer will say to you, "How do you know the pt. was sleeping and not in a coma or dead?" Chart, "Pt. respiration's even and unlabored at 14 per minute, skin warm and dry."

You will find many references to what to chart, document on other sites in All Nurses.

[AgentBeast, BSN, RN]

Document everything. As for the barrier cream I would say "Barrier Cream applied per CNA."

[nurse2033, MSN, RN]

Just like you said, I think you got it.

[darren_callcareer18]

Back then I also questioned what are those things I should document on nurses notes ( Until now). I posted the same concern here and the replies really helps me alot. I also made my own research and some readings about the correct documention for nurses and the summary of it are:

1.First thing, is to find out what is the documentation style applies in your institution whether focus, narrative, Problem oriented etc.

2. Document only what you have observed and the only nursing actions that you have performed.

3. Never look or copy how your co-worker charts.

4. Document timely, accurately and patient centered.

5. A procedure that has been performed but not charted is considered not performed.

It's ok to chart very long notes as long as you really did what you have charted/Documented.

[CapeCodMermaid, RN]

Document everything. As for the barrier cream I would say "Barrier Cream applied per CNA."

The CNA's document on their own. No need to include it in a nurse's note. If the person is Medicare, you should document something about the reason they are there. If, for example, they are there status post hip replacement, you should document on their level of pain, bed mobility, anticoagulant therapy. My least favorite nursing note to read is: "Resident verbal, pleasant, ate well." Medicare doesn't care if they are pleasant or not.

[Forever Sunshine, ASN, RN]

Instead of sleeping. I put "resting in bed. No signs or symptoms of pain or discomfort"

You don't need to chart for barrier creams. But if they have a treatment and thats why your writing the note. I usually write, "Tx in place to left forearm.. no signs or symptoms of infection."

[brownbook]

Well, as I said you will get 15 opinions and many will tell you to do the exact opposite thing!

I don't know why you would never look or copy how your co-worker charts? Of course you have to do your own assessment. Not NOT do an assessment just copy what the previous nurse wrote! But I have found some nurses have a better way of phrasing common assessments, better ways of describing what you might find hard to describe. (As I am struggling to express myself eloquently here!!!)

What is, "skin warm and dry, no apparent distress, respirations even and unlabored", etc. but just "copying" what other nurses write (AFTER doing their own assessment)?

If you assess some change in a patients condition you should read the nurses notes. See if other nurses noted it (and hopefully intervened if necessary) or it is a new condition.

[BabyLady, BSN, RN]

When I was brand new, I would read the charting of other nurses and eventually came up with my own way to document that covered what I felt was needed.

You do not need to do "double charting"...for example, if you have a flow sheet that has vital signs, breath sounds, pretty much anything else, you do not have to list them again in the nurses notes, as long as the flow sheet has a time. It is also acceptable (even legally) to reference another document that is part of the patient chart.

[DDdove, LPN]

Thanks everyone and I guess everyone has their own way. I understand when you say only document what medicare needs. Do you know if you document each shift on every patient in LTC or just those needing assessed for a reason and medicare. Is every resident assessed for vitals every shift? I have never worked in LTC before and I am really nervous about starting.

[BabyLady, BSN, RN]

Thanks everyone and I guess everyone has their own way. I understand when you say only document what medicare needs. Do you know if you document each shift on every patient in LTC or just those needing assessed for a reason and medicare. Is every resident assessed for vitals every shift? I have never worked in LTC before and I am really nervous about starting.

You document what will cover you legally or any significant intervention.

My rule of thumb: If I cannot look at my charting in 3 to 5 years and know what I did with a patient or could not answer questions...then I have not charted enough. If it is not charted, it didn't happen.

[Forever Sunshine, ASN, RN]

Thanks everyone and I guess everyone has their own way. I understand when you say only document what medicare needs. Do you know if you document each shift on every patient in LTC or just those needing assessed for a reason and medicare. Is every resident assessed for vitals every shift? I have never worked in LTC before and I am really nervous about starting.

No omg no. CNAs get ****** when we get vital-crazy(which happens when theres a flu/virus that goes around)

You document on a resident by your facilities policy. Not each shift on every patient.(Theres not enough trees in the world to make paper to do that lol).