Assessment question? Is this common?

[tsm007]

Okay, I am a brand new nurse in a skilled nursing home. I am trying to do my skilled assessments so I tend to look back at other nurses charting for ideas on wording and to figure out patient's baselines. Well, I am noticing a trend. I have one patient that has had a stroke, right sided paralysis, and weakness on the right side. He is in a wheelchair. He needs 1-2 people to transfer (depending on how much he wants to help that day). So anyways I'm reviewing his assessments and most of the nursing assessments have normal marked for ALL extremities on their neurologic assessment. Even the admission one has normal. Well of course now there's a memo from management on my assessment that says "Is the weakness new? Doctor notified. Monitor and document on"

Am I wrong? Should I be charting this as normal? I am not the only nurse that has charted this as weakness, but most nurses chart this as normal. I am seriously seeing most everybody charting everything as normal and just putting in vitals (unless there's something new that's wrong). I don't feel like tackling everyone else's problems, but I want to do the job right. Should I be charting this as normal if this is normal for the resident?

[Wallace2014]

I'm a new nurse in rehab/hospice/LTC facility... When charting, I do go back and view what other nurses has written as well... I use their notes as a comparison or baseline as to what I saw... I ask questions and leave the electronic chart open but saved until I get an answer... If I forget to close it then my supervisor will let me know the next day and I ask her to assist me... I have found errors from other nurses but I still chart what I saw and be as detailed as possible without writing a page...

[sueture]

haha and YEP!

[LockportRN]

Your colleagues are not actually assessing the patients. Let management take that up with them. You chart your findings. If the patient really did develop a new hemiparesis, of course that's something you'd need to call about.

In the future, you may want to write something like "left sided weakness unchanged from previous assessments." or "Left side weakness per patient's norm.". This would give an accurate picture of the patients' functional ability while not causing alarm to management. Though I am very surprised that it went any length of time without MDS/DON/ADON being aware. It seems as though they do read your charting which is good, but am surprised that MDS at the very least, did not actually go see and assess the patient.

As a manager, we would all go to meet the new patients the day of or day after their arrival. MDS always went to the patient and completed their own assessments.

[amoLucia]

Someone you might want to ask for help is your MDS/RNAC Coordinator. That way your charting will accurately reflect the data/factors that direct facility reimbursement (and will match MDS documentation).

And FWIW, I also reviewed other nurses' documentation to check if I missed something. I also learned how to better phrase some things for my own charting and to catch any errors in other charting. A simple example was when a prior note would document "O2 at 3L via canula", yet the MD order was for 2L. Had the pt had any problems not charted on by the prior nurse? Was the MD notified and new order obtained? What was the followup? Can you see where this went? And if a surveyor (or lawyer) caught this as a discrepancy, what would the fallout be?

And then when the previous note TOTALLY omitted a significant change - like I have to chart on a newly reinserted GT but there 's no prior note. A late entry is better than a missed entry.

The only way that occurs is if I review others' charting. I chart for myself, but I do review others'. And I have been doing it for many, many years.

I digress...

[hppygr8ful, ASN, RN, EMT-I]

Thank you all so much. I feel like I have learned so much. I have been very insecure in my assessment abilities, but I'm realizing I'm doing better than I thought. Second and perhaps even bigger thing I have learned is I am going to be even more thorough in my assessments and more detailed in my charting. I will try to put detailed notes on my charting about any abnormals being chronic or new so that anyone reviewing the chart will be aware that these are "normal" abnormals for the patient.

I might also like to note that patient's can present very differently from shift to shift. A patient may be peachy keen perfect on dayshift and go into sundown mode when the sun goes down. Good assessments help provide develope plans of care to deal with these things.

[lumbarpain, ADN, RN]

working in LTC for many years...many many times I have done assessments and found a cargo load of discrepencies and omissions....however...I try to talk to the nurses that have done these assessements if I can..and question them face to face...then you find out more information on why they came to their conclusions...but this may be an impossible task...nursing homes have a revolving door at times with staff. I try to be as consistant as possible on my job....if I notice anything different in my assessment and other nurses I go to my nurse manager...if you have a good nurse manager...she will follow through. Having a good TEAM on duty when you work is so so important.....personalities, work ethics, knowledge, sense of humor, compassion, and adherence to routine and protocol is essential... The whole machine must work...one part that doesn't can really upset the whole workings of a team...I have experienced that a lot on my job.

[BoyNamedSue]

When I started out on skilled, I would pick up every now and then on another skilled unit in the facility. I would go around doing my assessments, and the patients would look at me all crazy (even though they weren't crazy). One patient asked me what I was doing, so I told her. "We do one every day." She said that no one else ever did any assessment, and wanted me to go. Very skilled to be able to do 7 assessments a day whilst never leaving the computer desk.