Just graduated RN school and landed a job in LTC night shift. I am really at odds with this facilities charting and documentation practices. I really don't know if I am 'covering my a$$' part of the time and can see how alot of things are being missed, but then some of the forms that we have to fill out seem so redundant, pointless and time consuming, for example, the pain management sheets (long story). When it comes time for the state inspection, I can forsee this place being 'hung out to dry.'
We do have a 24h report sheet and i am responsible for making it out and deciding who should be on it and who should be taken off. Also, theoretically, everyone on there should be charted on, but it is not happening. There is not time.
The problem is, I was never given any formal guidelines. I have asked other nurses, they don't seem to know that there are any, nor do they care. Everyone seems to have their own 'rules' and there is no consistency. The DON who hired me just quit on short notice, so this place doesn't really have any effective leadership.
So if anyone can give me 'the basics' on how the charting process should work, I would appreciate it, as well as any pointers to make it faster, while making sure you cover yourself.
Also, when a resident comes back from the hospital on medicare, how long are they on medicare and how long should you chart on them? I am sure that is a stupid question, but none of the other nurses I work with know, either.
Appreciate any info.....thanks!!