Daily Documentation..how do ensure you get it?

Specialties MDS

Published

Specializes in LTC-Geriatric-PPS-MDS.

How do you guys ensure you get daily documentation on the nursing skilled DX that you put on cue sheets for floor nurses?

My issue for example: I put out cue sheets for each skilled patient (updated at least weekly ). One patient I had for nurses to observe/assess respiratory status due to Dx pneumonia. Yet, we are getting no nurses focusing on what I am asking for...they just do the generic ADls and move on..

Or wound care for surgical sites or pressure ulcers...Never get daily documentation on the actual wound site- just generic "dressing C/D/I"

Suggestions? I have inserviced what seems like 8 million times! Tired..

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Specializes in NICU, ICU, PICU, Academia.

I guess my question is "What is the consequence for nurses failing to document the areas required?"

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Specializes in LTC-Geriatric-PPS-MDS.

Seems like absolutely nothing to me. My hands are tied with that tho. I can only present it to my DON of the inadequacy.

"Have you educated the specific people and got them to sign your in services?" YES! Speficially one that was HIRED to do Medicare charting Mon-Fri...

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Specializes in LTC-Geriatric-PPS-MDS.

I guess what I really am wondering--- what are you guys expectations on daily nursing documentation on surgical sites, pneumonia,chf, cdiff, staged wounds?maybe I'm expecting to much... Unreasonable. (But I don't believe I am...)

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Specializes in Hospice + Palliative.

I can only speak to this from the staff nurse perspective, since I *just* got offered an MDS coordinator position today and haven't begun working from that end of things. Our facility has had a hard time getting nurses to chart appropriately, despite cue sheets and fyi/reminders on 24 hour reports frequently. One of our supervisors has been piloting something new - putting in the specific documentation requirements as part of our eTAR (we use Point Click Care software) so it goes in as "assess respiratory status each shift and document", or "Assess and Document per CHF Protocol" or CDiff: Assess and Document Bowel", or if someone is on antibiotic for a URI: "Assess and document vitals and lung sounds r/t URI". It's pretty ridiculous that these tasks need to be put in for each shift, because one would think that nurses would know that these assessments need to be done; however, with rehab and skilled nursing facilities being staffed short and nurses being overwhelmed with work, this is where we're at. The unit that this has been implemented has had a significant increase in appropriate detailed and accurate charting. So - sometimes doing a lot of handholding works ;)

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