Okay, it's "weekly summary" time !
- 0Oct 23, '04 by PHTLSEvery 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)
- 0Oct 25, '04 by donmomofnineWe do "monthly" summaries for the first three months after admission or hospitalization. Then we only do quarterly summaries to coincide with MDS. We us a form with checklists or blanks to fill in addressing locomotion, assist needed, meal consumption, cognition, incidents, etc. Works for us, though staff still refers to them as "monthly summaries". Old habits are hard to break!
- 0Nov 16, '04 by CapeCodMermaid, RNWe do shift notes on all Medicare and Managed care patients and chart by exception on all the long term patients. We do a monthly summary on ALL residents. Not too bad on the LTC floors, but horrible on the sub-acute unit. Frankly, I don't understand why someone who has a nurse's note every shift and a 5,14,30 day ...MDS needs a monthly summary. Talk about overkill and duplication of services.
- 0Nov 16, '04 by AntikigirlThe reason I was hired was for these, but since we lost a nurse I have had to be the floor nurse to fill in till we get another one...6 months and counting now....UHGGG!
Actually we have monthy brief summaries on complex residents only, then the others get an eval before their service plan meeting with the family every 3 months. There is a form to fill out and it is rather cut and dry...takes time, but very basic. Anything more complex or needs addressing, I mark down and have the nurses follow up that week.
If someone wants a detailed summary of the month..get to reading the care notes and faxed orders in the chart..it is all there! (Our State agrees with that concept).
But then again my facility is overboard in the charting department...alert charting for things from a sniffle to edema (q shift charting till a Nurse D/C's the charting), q shift charting for all hospice, IR/alert charting for any skin issue (even a <1cm yellowing ecchymosis!!!!!!), and highly detailed follow up charting by the licensed nurses...including 24 hour communications for CNA's/RN's, faxes to doc on all issues, IR for EVERYTHING, MAR monitoring by RN orders on any issues, and follow up (and the stuff I did). Believe me...if a resident gets a pimple you will hear about it in detail till resolved! LOL!!!!!!! Makes for HUGE charts!!!!!!!! LOL