LTC Charting: A Beginner's Guide LTC Charting: A Beginner's Guide - pg.4 | allnurses

LTC Charting: A Beginner's Guide - page 4

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  smshelby profile page
    2
    Thank you for sharing this article. I've been a LPN for 30+ years with 0 experience in LTC and have just started working at a SNF and I have to tell ya, the charting and duplication of documentation has been and still is a huge stumbling block. Making things even harder is that the facility I'm employed at is totally old school (no computers) Felt like I stepped back into the 80's. There's a form for everything!!!! I've bookmarked this and would appreciate any helpful tips for my new journey!! Love this site!!
    vintagemother and rnprettyblonde like this.
  2. Visit  MandieeRN profile page
    1
    Love it!!!
    TheCommuter likes this.
  3. Visit  Gigi72 profile page
    0
    gosh this is so helpful. think i will have to print this one.
  4. Visit  jar312 profile page
    0
    Thank you so much! This helps a lot!
  5. Visit  emilynyb profile page
    1
    We are required to notify family of each medication, medication change or even if the medicine has been discontinued.
    TheCommuter likes this.
  6. Visit  Khalesi25 profile page
    1
    Thank you Commuter!
    TheCommuter likes this.
  7. Visit  downsouthlaff profile page
    1
    This is an awesome post ! Very helpful to a new nurse like me without previous experience going into a new job at in LTC.
    TheCommuter likes this.
  8. Visit  AshortenRN profile page
    1
    I will be making full use of this! Thank you!
    TheCommuter likes this.
  9. Visit  cree0165 profile page
    1
    VERY useful info. I feel more confident about charting now. Thanks!
    TheCommuter likes this.
  10. Visit  cinnybug profile page
    1
    At the facility that I work at we chart all of the aforementioned as well as weight increases/decreases of 5lbs or more. We also have to notify the MD and RP and chart that as well. We also chart any dietary changes or therapy orders ( new or d/c'd). And let's not forget meal completions and hydration notes. We also have to document at least three different methods of alternative resolution before we administer a PRN Narc along with the effectiveness after administration. We have to chart mood/behavior for 72 hours when any psych or depression med is started, decreased or increased. Thank goodness I type very fast!
    TheCommuter likes this.
  11. Visit  TheCommuter profile page
    1
    Quote from cinnybug
    Thank goodness I type very fast!
    And thank goodness the LTC facility where you work seems to utilize electronic charting, or else all of this added documentation would take forever and a day...
    vintagemother likes this.
  12. Visit  vintagemother profile page
    0
    Quote from TheCommuter
    And thank goodness the LTC facility where you work seems to utilize electronic charting, or else all of this added documentation would take forever and a day...
    Yaaaaaassss!!! This! When my LTC facility moved to electronic charting of meds..... My life became much easier! I became so much faster at the super huge med pass!

    Who would have thought my slowness was related to flipping through umpteen MAR pages in 2 binders!

    And the check boxes to do assessments and inability to save a doc unless it was complete? ..... Priceless!!!
  13. Visit  cinnybug profile page
    1
    Lol.you're right! We do use EMAR and PCC. Even so management still dictates that we have to do additional charting in our progress notes on what we charted in EMAR or PCC so that they can see it during their morning meetings. So even though we document VS for instance in EMAR we still have to include those signs in our alert charting via a progress note in PCC.
    vintagemother likes this.

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