New to LTC - Charting Question

  1. Hello,

    So I have plenty of experience (Stepdown and ER) in a hospital setting, but the 12 hour shifts were causing some difficulties with baby sitting. So I took a job (while staying per diem at the hospital) at a Rehab facility very close to home. It is 8 hour day shifts and the schedule is steady. But the charting makes me uneasy. There are about 20-24 patients on the floor. It is electronic charting, but it is VERY old. I've only oriented two days, but the charting seems to mainly be that wound care was done (not how the wound looked or progressed) and that eye glasses are in place. Nurses commonly borrow medications from other patients, and isolation / infection control consists of gloves and hand washing, no gowns or other protective wear.

    Is this common? I'm used to head to toe assessments. I'm also used to not borrowing meds and knowing if a patient has MRSA, VRE, etc. They have had a hard time keeping nurses. I'm starting to wonder if I should plan my exit. Thanks!!
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  2. 5 Comments

  3. by   CapeCodMermaid
    Welcome to the world of long term care. You will never have time for a head to toe assessment of every resident you're responsible for. You'll do a focused assessment. If they are there for exacerbation of CHF or COPD you'd focus on the respiratory assessment. If they are there status post hip surgery, you would note the condition of the wound, the level of pain, anti-coagulant use and the like.
    You shouldn't borrow from one resident...it happens but it shouldn't. And there must be policies on PPE depending on the need for precautions.
    If you IM me your email I can send you a charting cheat sheet. I've used it in 5 facilities and have seen it in another.
  4. by   NJ2010RN
    Thank you for your reply!

    Unfortunately, it seems like assessments aren't being charged at all. They just chart if they cleaned a wound, if eyeglasses are in place, etc. Not change in pt status or even a focused assessment, except on admission. I'm getting more and more scared for my license. They had an auditor come in, and many errors were found by the staff.

    Now it seems that taking pictures of wounds from personal cell phones and sending them to the doctors are common place. That just makes me uneasy. My phone isn't encrypted to prevent a HIPPA violation.

    Oh the flip side the people are so nice, the hours are good and location is so close.
  5. by   CapeCodMermaid
    Your license isn't in jeopardy if you're doing your job. You can't be held responsible for another nurse's mistakes.
  6. by   jdub6
    chartingvems to mainly be that wound care was done (not how the wound looked or progressed) and that eye glasses are in place. Nurses commonly borrow medications from other patients, and isolation / infection control consists of gloves and hand washing, no gowns or other protective wear
    Borrowing meds isn't good practice 19 legal but realistically it happens in many facilities. Best way to minimize it and ensure you don't get stuck with no meds and encouraged to borrow is make sur÷ refills are ordered promptly and the emergency stock is filed.

    infection control in LTC is totally different. those with MRSA OR VRE his8tory or colonized are standard precautions and there is no need to know who they are. those with active infection are contact. however they and their visitors can be asked but not required to stay in their room, wear masks, wash hands or whatever. while gowns are required for staff in the room, i personally would not take time from med pass to put one on just to hand someone their pills.i just don't touch or sit on anything. i do wear gloves.
    Last edit by jdub6 on Mar 24
  7. by   jdub6
    Unfortunately, it seems like assessments aren't being charged at all. They just chart if they cleaned a wound, if eyeglasses are in place, etc. Not change in pt status or even a focused assessment, except on admission.
    what are the policies and Medicare requirements for charting? often a daily, weekly or even monthly nursing summary is the only place really requiring an assessment as well as progress with active issues/treatments/care plans. other than that no assessment needs to be charted on someone during an average shift unless condition changes and usually thats just a brief focused assessment,what interventions done, orders obtained and effectiveness. i would chart a wound assessment with dressing change unless it is changed qshifr or more- then daily might be okay- or if the dressing is just to cover a long term totally stable skin lesion that is not going to be treated. stuff like that i chart assessment onlyif there is a change. but check-if you have no treatment record and a note is the only way to document that he order was followed, an assedsmenr might not be required that often (if you had a TAR is just like a MAR and you just initial in the date box-no room to doc assessment, and policy often is weekly or even q2wk assesment.

    Now it seems that taking pictures of wounds from personal cell phones and sending them to the doctors are common place. That just makes me uneasy. My phone isn't encrypted to prevent a HIPPA violation.
    this actually is not unusual and not necessarily against HIPAA. if the photo is up close the patient should not be identifiable and if no identifiers are used in the text this is okay although may be against policy.

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