Hello! I am an ICU RN working as a weekend wound care nurse PRN in an LTC. In ICU, I understand what is to be documented...If it is not documented, it was not done...
That being said...
In LTC I have been told by the DON on several occasions...you can't document that!
My question is; is there documentation guidelines for LTC that are online or printed material? I have looked online with no luck. I have combed the facility also, looking for some type of reference to guide me in this new world...No luck there either.
I have also found, while working in LTC, that pt advocacy is frowned upon. So, if the full time treatment LVN wrote an order...The weekend RN is not suppose to question it (according to the DON). I am having a hard time swallowing that... Don't get me wrong...I am not devaluing LVN's...They are a VALUABLE ASSET! This particular LVN however, has no official wound care training and is a friend of the DON's.
So, I need some help. Anyone have suggestions? Links? Experience relating to this dilema?
Thanks in advance.