- by username33 Sep 19, '11I just started my job as a RN in LTC. I was told that I don't need to chart on all my 20-25 pts every day only on pts from the alert book. Important to chart on Medicare residents everyday. I am wondering what exactly I need to chart? Can anybody give me some examples of charting in LTC?
- Sep 22, '11 by CapeCodMermaidFor any Med A patients you need to chart on the reason they are there for skilled care. For example, if they are there with a total hip replacement you would chart on the incision, the level of pain, their working with rehab, anticoagulation and the like. Don't bother with 'pleasant, ate well.' No one cares. If you search through the Geriatric Nurses posts you'll find a medicare charting guideline.
For the non Med A patients...chart by exception.
- Nov 2, '11 by Shawn_RNI would ask for your facility policy as to what the charting requirements are. CapeCod is right MedA is one of the most important in that you have to document the reason for the stay as she mentioned. Most facilities spell out their charting requirements and it should have been something that was given to you during your orientation.
- Nov 2, '11 by caliotter3Some of the facilities where I worked would give medicare charting 'cheat sheets' to the nurses and have inservices on charting. I would ask your facility if they have such a document or perhaps you can find something online.
- Nov 2, '11 by CapeCodMermaidThis is what I've used in 3 buildings (so far). I hope it helps.
- Nov 3, '11 by AmyS,RNI love that guideline from capecod. I really try to chart on everyone, including any behaviors. I never really liked the charting by exception concept, it seems in LTC almost everyone has something to be monitored or addressed. The medicare does require a little more extensive charting, and I try to rotate the thoroughness of the 'more stable' residents, understanding that time isn't abundant. It feels that in LTC more focus is on getting through the med passes vs assessments and critical thinking.