LTC Flow

Not everyone gets a note every day. Generally you chart only if something is off. Out of 30 residents, say, you could have five to fifteen nursing notes to write. And you'd put them on your report sheet before they ever get to the chart.

I wait till after the med pass. Too many meds to give to take time to stop in the middle. If the charge nurse is aware of a situation, she will sometimes write the NN. Otherwise the LPNAC gives us a list weekly of residents who need to be charted on for Care Plan. And as Suesquatch said, chart on res if anything is off

If you're working traditional nursing home LTC, then you only chart by exception. This means that you document only when something is occurring that is out of the ordinary with one or more of your residents. You'll also want to document new orders, antibiotic therapy progress, and all encounters with the resident's physician in the nurses notes. When I worked traditional LTC, I documented well after all the meds had been passed, and only when there was a moment of uninterrupted downtime.

Now I work on the skilled nursing rehab unit at the same LTCF, and since all of these patients have Medicare as a payor source, some charting must be done on all of the patients at least once every 24 hours. Still, I wait until all the meds are passed and treatments are completed before I chart on them.