adding to the paperwork

Lexxie, LPN · Nov 14, 2009

You mean the quarterly pain, fall risk, elopement, etc. assessments? At my old facility, floor nurses had to do them as well. They were divied up between the shifts - days did pain, evenings - fall risk, etc.. Could medical records pick up the TB tracking, since he/she audits the charts anyway?

sasha2lady · Nov 16, 2009

Yes....these quarterly assessments consist of side rail screens, smoking, incontinence, braden scales, pains, immunizations, lift assessments, and a few others that i cant remember right off the top of my head..but its a hugeeee stack...and these have always been done by MDS RN's. I wondered the same thing..apparently the med records person audits charts monthly and we are just now finding out about it..only because she put a list of junk at the desk that we had no idea what it was for....because these people have been discharged for weeks. I dont know why she cant go through and handle the yearly TB stuff..but our ADON has always done this and gave us a list of who was due. We each have a folder now and its got so much JUNK in it and we dont know what exactly we are supposed to be doing with it.....its got sections on there about labs.....like...for synthroids, depakote, dilantin, antipyschotics, etc etc.....does she want when it was done? or when its due again? Who knows. Plus its got a few slots on there for chart checks....which are supposed to be nightly on third shift....on my 8 pts....none have been done as far back as august. ME and another nurse found multiple lab and med errors by having to dig through this stuff. A yearly TSH wasnt done when it was due.....so I had to put it down to be done this am. It was due the first of november.....we found multiple tb tests that hadnt been done , several 2nd steps that hadnt been put on new mars so they are months late.......some were never even read. Some havent been done since 07. Plus there are sections on there for us to check every day if the aides are doing their flow sheets...umm......how are we supposed to find the time to do this???......And if the med records person has actually been auditing these charts monthly...then why hasnt this tb stuff been brought up prior? Plus....she doesnt thin charts correctly.....the chart is supposed to have the last 4 mos worth of info in it when they are long term here......I found labs from 07 and 08 and all of 09.....piles and piles and piles of them. No wonder the charts weigh over 9 lbs ( I weighed them last night on the scale)..and papers fall out of them nonstop. If we had a computer system in place this would be soooo much better...just a point and click on whatever info we needed access to. None of this messy paperwork and disorganization. I have become soooo confused by this stuff.....but I dont think its fair for us to have to do the mgmts job. When a nurse asked the boss whos job this was......she said "yours"...referring to us other nurses....and I was thinking " since when??????"....Ive been a nurse for 3 yrs and never had to do quarterly stuff....or keep track of yearly tb tests etc..she even said that they didnt have time to go through the charts daily.....yet they say we do???? Im just not following how this is going to be effective. On top of that.....they want us to babysit aides and deal with all their problems and issues instead of them actually doing what needs to be done. Its not my job to keep up with how many times people call in etc etc......that should go to someone else.