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?
Jan 19, '13
I'm a wordsmith when it comes to documentation. I would rather write more than less. I chart whatever I have to. I probably am one of the more prolific charters at my job.
But on nights generally not so much happens, so don't write too much, you know?
In the instance of the Foley ask your aides if you can see the urine, or empty it yourself. Document patency c/o pain etc.
Jan 19, '13
I like the KISS rule keep it short & simply
DAR notes are good for that .... night shift there may not be a lot happening ..... which is a good thing meaning everyone is sleeping no unusual occurrences. Chart ineffective findings only with a intervention and outcome
otherwise keep it simple ..... sometimes less IS more
Jan 28, '13
My rule is cover your basics for your Med A, MDS, cover alerts and anything new. Cover it briefly. We have some nurses who chart about things that we just don't need to know about. If you have time to do that, you probably have time to do something else. I can guarantee you there's always something that needs to be done. As far as relying on your CNA's-I rely on them no matter what shift I work. That's part of their job. I don't check every toilet when someone goes on my hall to see what size bowel movement they had. I don't go measure the amount that each of my resident eats at every meal, that's dietary's job. If a resident has something going on where these items are relevant more than just a normal thing, I will check them. As a team everyone has a job and we work together.
So, went off topic a bit. But as far as your reference goes. If you are monitoring the output on the resident with the foley, then yes I would probably check it myself, however, if its just a normal end of shift cath bag dump for a resident with no issues and a permenant indwelling cath, I wouldn't be measuring it myself. As far as color, when you do your shift rounds its a quick look to see if color and such are what they should be.
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