Tips on charting in LTC

amoLucia · Feb 23, 2016

There's been other posts re charting. One suggestion is to find someone else who charts well and try adopting that style.

And just a word of caution - be careful about repeating a previous chart entry esp if there are specific details. I've seen where a previous entry will record "O2 at 3L via canula", yet the O2 really is at 2L and that's what the order is. Another good one and very frequently wrong is "cast on LEFT arm intact", but the cast is on the RIGHT. Enteral formulas and flow rates also change and documentation discrepancies occur.

Not sure how experienced you are but if you're new to nsg and/or LTC, don't take offense if your UM/supervisor/SDC reviews your charting. With all the emphasis on documentation, they most likely will be checking. They really not picking on you, they just need to make sure things are accurate.

TheCommuter, BSN, RN · Feb 24, 2016

I wrote about LTC charting a while back. Click on the link below if you are interested.

https://allnurses.com/geriatric-nurses-ltc/ltc-charting-a-899111.html

Also, the D.A.O. (data-action-outcome) charting format works well in LTC. You record the data, document the action you took, and record the response.

Example:

D - resident's temp is 102.1 degrees...urine is dark, cloudy and odorous

A - administered Tylenol 650mg p.o. per PRN order for elevated temp; telephoned Dr. Jones to report change in condition

O - temp rechecked at 1500 and was 98.9 degrees; new orders received to obtain UA/C&S and encourage hydration; no acute distress observed at this time

Adele_Michal7, ASN, RN · Feb 25, 2016

I usually start with the beginning of the shift and what that looked like, while keeping things relatively general- AKA,

Patient receive during shift change with stable VS, no indicators of pain during LN rounds, and resting in bed/visiting with a friend/working with therapy...

Then I'll add in any patient specific hot topics that need to be addressed. AKA,

Continued on PO/IV ABT for condition X as ordered, no adverse reactions. (You would also mention PEG feeding infusing at 65mL an hour, etc.)

Then I'd add in any PRN medication given, AKA...

Administered Melatonin at 2100 as ordered to promote somnolence and patient comfort. Meaningful effect AEB patient resting with closed eyes, deep unlabored resps upon reassessment at an appropriate interval...

Do you have any other specific questions?

allnurses Guide · Mar 2, 2016

Sorry I'm late chiming in on this - Basic daily Medicare charting needs to address: Level of consciousness, orientation, appetite, wt gain or lost, Bed mobility, transfer mobility, ADL ability. Participation or lack there-of in treatment. so what you get is something like this.

Resident is awake, alert, oriented to person and place, and able to participate in his/her plan of care. He/She is making good progress in therapy. Resident remains on IV ATB (Medication name) with no adverse reactions noted. He has a good appetite, eats 100% of all meals and has had no significant change in weight. He requires extensive assistance with Bed mobility, transfers, ADLs and toileting. We will continue to monitor for progress and safety.

Bam

Hppy