It seems as if you work on a skilled unit at a nursing home. Am I right?
I work on a fast-paced rehab unit at a nursing home. For medicare charting, I pick a few significant things that occurred with the patient, then I'll chart a paragraph on them. You can chart about IVs, antibiotics, PEG tubes, diabetic management, responses to PRN pain meds, responses to breathing treatments, skin condition, wound appearance, surgical incisions, dressing changes, patient behaviors, any injections given, oral care, baths, toileting, ADLs, ambulation, new orders, doctors' visits, and so on.
I'll also give you some time management tips that might keep you from getting overwhelmed. I work 16 hour shifts, from 6am to 10pm. Typically, I have about 15 patients to care for. At the beginning of the shift, I'll go through the MARs and TARs with a fine tooth comb and, as I go, I will jot down the things that must be done in my notebook. My notebook is how I organize the rest of the day, and I usually won't forget to do anything. Here is how Sunday's notebook page looked (names have been changed due to HIPAA):
DIABETICS, FINGERSTICKS: Agnes (BID), Agatha (AC & HS), Bill (AC & HS), Wendy (AC & HS), Rex (BID), Jack (BID), Esther (AC & HS), Margie (0600, 1200, 1800, 2400)
NEBULIZERS: Margie, Esther, Bill, Jack, Jane
WOUND TREATMENTS: Jane, Bill, John, Jack, Lillian, Rose, Lucille
IV THERAPY: Wendy (Vancomycin), Laura (Flagyl), Rex (ProcAlamine)
COUMADINS: Agnes, Agatha, John, Lucille
INJECTIONS: Agnes (lovenox), Jane (arixtra), Rex (heparin), Bill (70/30 insulin), Esther (lantus), Mary (vitamin B12 shot)
ANTIBIOTICS: Wendy (wound), Laura (C-diff), Rex (pneumonia), Agatha (MRSA)
1200, 1300, 1400 meds: Margie, June, Rose, John, Jane, Jack
1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura
REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Jane's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...