LTC Charting: A Beginner's Guide - page 4

by TheCommuter 18,187 Views | 39 Comments Senior Moderator

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
    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.
  2. 0
    like it!
  3. 0
    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.
  4. 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'.
  5. 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.
  6. 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...
  7. 1
    So helpful! Thanks a million!
    TheCommuter likes this.
  8. 0
    I love this! Thanks
  9. 0
    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.
  10. 0
    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!!


Top