I have 8mos experience in LTC working 3-11. I just started a new facility working overnights. The documentation is so very different. Im literally writing 2 or 3 sentences, and it feels too short.
It appears the overnites rely more on the CNA for documenation purposes. For example, several pts have foleys. Nurse documented 500cc clear yellow draining..BUT that was based on the CNA's documentation- preceptor did not assess herself. I feel more comfortable assessing my patients, as that is what Im accustomed to from my 3-11 shift. Any advice from overnight RNs on documenation/assessment practices?