Progress Notes

[ricksy]

Can anyone help with knowing when and which residents in LTC to do progress notes on...other than the ones MDS nurse tells you to? What do you really chart? My DON told me that "this" is their home and not to do the 'bowel sounds x4 active' stuff. What do you chart? Help! New nurse!

[chrisrn24]

You don't have to chart or do assessments on everyone just because they are there. With my long term patients I usually only end up charting on 4-5 out of 30 a shift...usually behavior issues or a respiratory assessment because resident K is on an antibiotic for pneumonia.

Chart if the person is on their 100 days of Medicare or whatnot but If they've been a resident of the facility for two years there is no reason to chart if you've got nothing.

For example, you could write "resident had emesis x2 this shift. Emesis was light green, small. active bowel sounds x4."

[NutmeggeRN, BSN]

We chart on shower/bath days unless someting else is going on. The note is expected to cover weight gain or loss (and correlate with diet intake) skin issues, VS, overall how their last week or so has been. Everyone gets a shower or bath at least once a week so this keeps an ongoing record. If there are other issues, falls, skin, resp etc then they charted on. Return from a hospital/new admit/fall gets charted on q shift x three days.

[venousr3tuRN]

We chart on shower/bath days unless someting else is going on. The note is expected to cover weight gain or loss (and correlate with diet intake) skin issues VS, overall how their last week or so has been. Everyone gets a shower or bath at least once a week so this keeps an ongoing record. If there are other issues, falls, skin, resp etc then they charted on. Return from a hospital/new admit/fall gets charted on q shift x three days.[/quote']

My facility is similar to this except we do what's called weekly summaries which, depending on which day and shift you work, you chart a progress note on 1 to 2 residents. This is on top of our 72hr charting which include the other issues like the previous poster mentioned. Just yesterday I had to chart on 10 residents on top of having to do the 2 weeklies. I'm working 2nd shift again today and will have to chart on the same 10 residents with 2 new weeklies.

[vicki518]

we chart on any "skilled" resident once a day

any incidents such as falls, vomiting, diarrhea, anyone on antibiotics chart x72hours

[Mn nurse 22]

Anyone with a condition change, abnormal vitals, antibiotic use, falls, return from the hospital, new admissions, behaviors, we have a report sheet of all the residents we are charting on, usually 5 or so and each shift adds or subtracts residents as needed.