Every nurse has to write a weekly/monthly summary right? Some days I hate it and somedays I can write a book on that particular resident.
What do you chart?
I usually start off from their cognitive abilities, s/e's from psychotropic meds, s/s of depression, B&B, nutrition, social habits (anti-social, abusive, flat effects, etc), pain complaints, skin integrity, any restraining devices, weight changes, ADL assistance, any events from their illnesses, and so on.
I get my info from their MDS, care plans
, CNA's, and talking to the resident (fun part)