At our facility, where we have 60 pt's /unit, each nurse on all shifts is responsible for 5-6 residents for a computerized monthly nursing summary. Half of the summary is on a template where you place an "X" for the answers to questions like,
( )Independent ambulation
( )Uses walker
( )Wheel chair
( ) Bed to chair
( )Ambulates with assistance
( )Uses cane
( )Geri chair
Then part of the summary you might fill the blanks like,
DIET AND NUTRITION:
current diet order:
EATS MEALS WHERE:
LIST ALL ALLERGIES:.....and so on and so forth. At the very end there is a section called...
Here you describe the pt (ie) This 78 y/o caucasian male, (Dx
with Dx of CHF, HTN, ASHD, schizophrenia-paranoid type, current vs., ADL's.Then you go on to describe any changes in his condition for the past month, eating habits/ (+) or (-) lbs past month, pt.educations, changes in behavior patterns, pain management therapy, does the resident attend any therapies, interaction with other residents any test or procedures he may have had done, any changes in medications and why, does he have any advance directives or limited therapies, DNR status, family involvement, d/c plans, and any other info that you might think is pertinent about the resident.
I couldn't imagine doing this form once a week. Sometimes the only thing that changes in four weeks is the resident's wt. We also do a nursing progress note for anything that may need documentation. (ie) pt spikes a temp, incidences that occur. you get the picture. Hope this helps!