LTC Documentation Guidelines

Nascar nurse, ASN, RN · Jun 12, 2012

I don't know of any particular links for documentation. Can you give some examples of things you were told you shouldn't chart? Maybe I can help explain why.

coffeebreakrn · Jun 12, 2012

Thank you for responding to my post.

:)

I put an order on hold because after assessment of a wound, I found there was no necrotic tissue...but a pink granulated wound bed. I documented that I put an order on hold and need for order clarification d/t Santyl medication (used to debride a wound from necrotic tissue...not to be used on healthy tissue) being inappropriate for wound at this time. I wrote an order for an order clarification for the physician. This order for Santyl was a new order that had just been ordered and to be started by me - the regular nurse did not implement this order; but took the order and wrote the order on the treatment MAR. The DON called me and told me that Santyl was ordered and could be used on the wound bed. She stated that I could not document or put an order on hold for clarification d/t change in condition of wound bed.

I also ask another physician for an order change using a collagen dressing over a stage II pressure ulcer and to cover the area with duoderm dressing. She told me that a collagen 2x2 could not be used under a duoderm dressing. She did not explain why...but this has been done by physicians on numerous occassions and wound care for Stage II pressure ulcers in several nursing books/literature indicates a need in some cases.

These are just a few things.

In ICU, you need to document everything. If an order is inappropriate, you need to question it and notify the physician prior to giving the medication or doing the treatment. If he tells you to go ahead and do it, you document that you notified him and he told you to proceed. If you feel like he has made a grave error...you need to notify your charge, NM, or DON to protect yourself if indeed this is a grave mistake that will cause harm to the patient. So why not here?

Also I know that incident reports are to NEVER EVER say that they were unwitnessed incidents, even if they were infact unwitnessed. I know the reason why... because "State" will make a call on the facility. And that is something that Every LTC facility that I've ever seen is afraid of. When State is in the house, everything is done letter perfect...Why not, when State is not in the house?

Any advice...? I know I am probably rambling a bit....

Thanks in advance. :nurse:

schej44 · Jun 12, 2012

I worked in sub acute and LTC for 10 years.. The documentation that these facilities do is VERY different then the hospital. The example you used about putting an order on hold and documenting that YOU put it on hold is a No No... The documentation should have read along the lines of your assessemt of the wound, the current order, and your call out to the physician for a clarification. After you got the clarification then the documentation should have read that physician clarified order and order was noted and carried out. Or if the physician changed the orders, the documentation should reflect that. Putting an order on hold without a written doctors order is unacceptable to LTC facilities. Always remember.. For everything you do to a patient, you MUST have a doctor's order, have an updated care plan, and the appropriate documentation. If not, the State will hang the facility, and in turn you will be in hot water also. NEVER put something on hold unless there are parameters or you have a physicians order saying to put it on hold.... Also.. every unit has a policy and procedure manual. In there you will find what the policy is for each stage of a wound. Always make sure you get a physician order and document the treatment in your note along with the assessment, and update the careplan.. Hope this helps

coffeebreakrn · Jun 12, 2012

Thank you. This helps a lot. I really am trying to understand. I will in the future refer to the P&P guidelines.

I was not aware that you could not place an order on hold pending clarification of that order in an LTC. That is good information to know. Thank you!

I did however do this:

assessemt of the wound, the current order, and your call out to the physician for a clarification

Dr is not alway readlily available at LTC, whereas they are usually at fingertips in ICU.

Thank you again for your invaluable information!!!

schej44 · Jun 12, 2012

Your very welcome.. You can always hold off on a treatment until later in the shift pending a clarification, but NEVER document YOU put the Tx on hold and there's no order to back you up.

Any other questions feel free to msg me..

CapeCodMermaid, RN · Jun 12, 2012

What disturbs me the most is your saying patient advocacy is frowned upon. We are ALL patient advocates since many times we are the only ones the patient has to speak for them.

I've been in the business since dinosaurs roamed the Earth. I document what I see and what I do. If I didn't see something happen, I document unwitnessed occurence. I document what I've said...what the doc said....what the family and patient said in a matter of fact way.

I've told all the nurses who work for me that they have to be truthful in their documentation. If you didn't see Mrs. Magillicutty fall on the floor, then it is an unwitnessed event.

"State" does not come out on every event witnessed or otherwise. They do expect that an investigation is done especially on any incident which causes significant injury.

nightwatchlpn, LPN · Dec 12, 2012

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.

I work in a residential school for severely dev. disabled kids. It very much resembles LTC in a lot of ways and I can tell you that I have been told on NUMEROUS occasions to not document certain things. I know that at least in my case it's more a case of administration trying to avoid parents filing lawsuits. However, to speak to the patient advocacy subject; I am in the same boat. I have a pt with a chronic venous ulcer, several years now. In trying to advocate for better wound care, different dressings (none were being used) and a possible consult with a wound care specialist, you would have thought I asked for the moon! I have received more flack for advocating for these kids than I am willing to admit. I had to make a report of child neglect to DCFS last year, and as a result, a direct care employee was terminated for neglect and a charge was found against him. I can say that my life here has been nothing short of miserable ever since...

At least 2 of my pts currently have wounds that would benefit from some real wound care, regardless of who performs it. Getting such simple things as orders for wound care, clarification on a lack of orders, dressings, etc is nearly impossible. I'm happy to say that student number 1 (the one I first mentioned) is now finally seeing a wound care specialist regularly (after one year of my 'advocacy' being ignored) after we hired a much needed RN who suggested it strongly. I have to say though, she said all the same things I had been saying for a year! The important thing though is that he's getting tx now. Student number 2, I guess we'll see.

I still document what I see, what I do, etc but have learned to work within the confines of such a facility to protect myself as much as possible. The question I always ask myself is "would the board of nursing back me up on this?" If the answer is "no" then I don't do it. Sometimes I guess it comes down to knowing that another job, I will find. Another license, I will not. As a supervisor, I encourage my staff to do the same as well.