LTC Charting: A Beginner's Guide - page 3

by TheCommuter Asst. Admin

14,054 Views | 38 Comments

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 specialty is projected to... Read More


  1. 0
    Thank you for the information I will put it to some good use!
  2. 0
    Good article.I am a RN but work long term as a LPN for ten years.
  3. 0
    I love this article. Thank you!
  4. 0
    love this commuter-Thanks! work in geriatric psych but these are excellent documentation purposes for me too!
  5. 0
    Great list!

    I work in acute care and while many of these items don't apply in the acute care world, there are some things that are good reminders. I'm going to bookmark this for future reference.

    Thanks for posting!
  6. 0
    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.
  7. 0
    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
  8. 1
    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.
    BrandonLPN likes this.
  9. 0
    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.
  10. 0
    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.


Top