Charting on 11-7

  1. I'm a new grad two weeks into my first job in LTC. We have to chart on skilled people every shift. On my shift most people are sleeping though. Most of my entries go something like this:

    VS T98.6 R16 P65 BP 120/80 O2 Sat 98% Resident resting quietly in bed with eyes closed. Breathing even, unlabored. No acute s/s of distress or discomfort noted at this time.

    If I give them medicine during my shift I note that they took it without difficulty (if they did) and quote them if they said something like "I'm doing ok".

    Is this really sufficient? It just seems so redundant to write the same thing over and over. Any suggestions?
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  2. 3 Comments

  3. by   caliotter3
    That about covers it.
  4. by   CoffeeRTC
    If you need to cover adls..how are they toileted? Inct or not? Did they get out of bed for the bathroom?

    Inct bowel and bladder, total assist for adls provided by CNA, turned and repostioned by CNAs, pillows used for positioning.......
  5. by   CapeCodMermaid
    It really depends on the admitting diagnosis. Were they admitted with pneumonia? Lung sounds, any s/s respiratory distress, any PRN nebs or supplemental O2. Ortho--pain, ability to move self in bed, amount of assist needed.

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