Quote from bzyadon
The nursing staff has very poor documentation when it comes to Med A charting. Multiple inservices have been done, but apparently nothing has changed. Our facility requires documentation per shift. I need tips in helping staff understand the importance of this.
I understand your frustrations with documentation, especially when it comes down to Med A charting. My facility is also in the same ball park. I am the MDS Coordinator and have educated my staff on the importance of Med A charting, it just seems like nobody really cares anymore, or "doesn't have the time" to adequately document all that is nessecary. What we have done is created a "Med A" form for each shift to use on a daily basis. This form has just about the same areas as the MDS does, such as, ADLs, Cognitive status, skin issues, and other critical areas that needs to be documented daily on. We finally got our nurses to at least fill out the form, but they still hardly do nothing in the area of a narrative subjective/objective notation on the patient that you wouldn't see from just ticking boxes.
We have also started a "dot" system to remind the nurses they need to document on specific residents. To give an example: Residents that take antibiotics need to have their temp. taken every shift and documented in their chart with noted absence or apperence of adverse reactions with objective information documented that our treatment is actually getting better. If someone has pneumonia we want to make sure that at least their lungs sound ok and the antibiotics are actually working. We also have a fall/new admission dot to remind the nurses to document daily and every shift on this topic as well.
We also came to the agreement that if nurses where not keeping up with a vital part of "nursing," such as documentation, then they need to be written up, especially after all the policies that we have developed to help remind the nurses to chart.
I was a ER nurse for 3 years before taking this position and I have been to court before and let me tell you, I was glad that I documented as well as I did on that specific patient I had to testify on. I really don't think most nurses understand that and but they will the first time something happens and they have to be responsible when they get a subpoena.