LTC Charting: A Beginner's Guide - page 3

The long term care industry (a.k.a. nursing home industry) employs a large share of new and experienced nurses in the United States. Furthermore, the number of nurses who secure employment in this... Read More

  1. Visit  4give&4getoften profile page
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    Very helpful list Commuter! Ty This may fall under admission?, but how about when a resident comes back from the hospital? I know some things may be cleared up with a phone call from the hospital nurse but even still residents come back sometimes with so many new orders. One time my MIL returned from a hospital trip and it was found later that her ativan was dropped from the orders and no one caught it until she was extremely agitated(w/d???).

    set of vs And to do a full skin assessment when back also. There have been a few times residents would come back with severe bruising from a needle stick or something else and if not found upon return it could be a real problem later.

    just my 2 cents
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  3. Visit  CapeCodMermaid profile page
    2
    Quote from BrandonLPN
    It boggles my mind that some facilities have policies in place to telephone the DPOA for something like a order for a new medication. I feel sorry for nurses who have to do this!

    Also, the response to PRN medication is documented on the back of the MAR, no? Having to write a nurses note as well just seems redundant.
    It IS redundant so my nurses don't have to do it. The med administration is charted on the EMAR as is the result. Why document twice?? If there were an adverse reaction or the med had to be changed because it didn't work, document that in your note. The rest is just making more unneeded work for nurses who already have too much work to do.
    Gigi72 and BrandonLPN like this.
  4. Visit  chrisrn24 profile page
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    Quote from CapeCodMermaid
    It IS redundant so my nurses don't have to do it. The med administration is charted on the EMAR as is the result. Why document twice?? If there were an adverse reaction or the med had to be changed because it didn't work, document that in your note. The rest is just making more unneeded work for nurses who already have too much work to do.
    Our PRN med admin ends up charted in our progress notes (automatically from the EMAR to the progress notes). It's awesome and saves so much time.
  5. Visit  prnqday profile page
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    This needs to be printed and placed at every LTC nursing station. I wish I had this, when I was a brand new grad LPN in LTC several years ago.
    Commuter, all of the things you've written has bee required at every LTCF and ALF I've ever worked in. Not sure why some LTCF are not notifying POA's of new orders.
  6. Visit  CapeCodMermaid profile page
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    Not every resident needs someone to speak for them. I have many in my building who speak for and decide things for themselves. There is NO regulation that says a family member needs to be notified of every new medication. If that is YOUR facility's policy, fine. It is NOT the policy at mine (or in any of the many I've worked in).
    As always, follow your facility's policy for everything.
  7. Visit  sweetkimchi profile page
    0
    like it!
  8. Visit  Veronica.c profile page
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    Thank you for posting this. I work in LTC and can attest to the accuracy of pointers you mentioned. It's a good recap and I would have loved to have had a copy so neatly laid out when I first started working.
  9. Visit  Sam J. profile page
    0
    Quote from tracyRNBSN
    I inform family members of every new or changed medication. It only takes a few minutes and if I had a family member in a facility I would want to be aware. It is also a requirement at our facility, even a simple order such as Tylenol or eye drops. I have to put a note in anyway so I make a quick call to inform the family members, who are always very appreciative that I called.
    Easy way to document this is on the order itself: Resident (or POA) informed. Also, by informing people of every change it saves countless hours of care plan time- in fact, many famly members beg off because they have already been informed of every minor detail in the past months. Also- if a resident or family refuses the new order, it can be called and cancelled right away (even better, talk to the resident beforehand to see if they will agree to the proposed order change(s))without creating a massive backlog of orders that 'need clarified'.
  10. Visit  Sam J. profile page
    0
    Quote from tracyRNBSN
    I inform family members of every new or changed medication. It only takes a few minutes and if I had a family member in a facility I would want to be aware. It is also a requirement at our facility, even a simple order such as Tylenol or eye drops. I have to put a note in anyway so I make a quick call to inform the family members, who are always very appreciative that I called.
    The P.R. value of all the constant calls and notations really is priceless- more so for the many families that can't or don't want to visit their relative in the SNF that can rely instead on the staff to be consistent and thorough. It also heads off a lot of potential problems in the future for those who'd like to be able to say "I NEVER gave consent for my Mom to take that", "I was NEVER notified that my Mom fell and broke her hip", etc.
  11. Visit  Sam J. profile page
    0
    Quote from BrandonLPN
    Also, the response to PRN medication is documented on the back of the MAR, no? Having to write a nurses note as well just seems redundant.
    Sadly, many places require it as back-up information because the MAR is so often left blank. As in: "OK- if we can't get the nurses to fill in a few simple boxes on the MAR or TAR- we'll keep thinking up additional ways in which to get them to complete their documentation". The obvious problem with the redundancy is that many times the MAR doesn't jive with the nurse note, and neither jives with the pain flow sheet, or etc...
  12. Visit  lakencassady profile page
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    So helpful! Thanks a million!
    TheCommuter likes this.
  13. Visit  RegenerativeNurse profile page
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    I love this! Thanks
  14. Visit  npakulski profile page
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    Thank you for the information. I am an LPN now for 2 1/2 years, I spent 5 months in an LTC facility and I was overwhelmed with how to chart correctly. I am in home care now, one patient at a time, and I love it, but my charting skills could really use improving. I am and have been improving slowly. This article is really going to help me now! Thanks again.


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