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Finallydidit 3,340 Views

Joined Nov 15, '09. Posts: 137 (34% Liked) Likes: 122

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  • Nov 3 '16

    Just a few things I try to include..
    If Resident complains of anything.. ie: headache.... chart what you did to fix it and when it was effective..
    Res complain of headache pain 4/10, PRN pain medication given, eff. @ 1/hr
    Also if a Resident is constantly non-compliant with care or meals, make sure that you document that the MD and family are aware of the situation. ie: Diabetic diet
    Res. non complient with diet orders, comsumes candy bars and sodas several times a day, MD and family are aware of behavior
    If documenting a new skin tear, along with a detail of what happened, I describe the wound, and then just add, cleaned and treated according to company protacals.

    Think of it like this... They pretty much want to know the issues and why they need to be there. So make sure to tell them.. They also want to know what you are doing to fix the issues and if they are making progress or declining, so make sure you tell them that too. If they are not making progress, (non complient with orders, diet, therapy etc.) Tell them what has been reported (to Mds, family) so they know its out of your hands and being further evaluated