Best Way To Document

[Nurse Andrea]

Hello. I am an LVN and I have been one for about 2.5 years now however 7 months ago I got hired for a pretty decent role. I got hired as a manager and coordinator for adolescence in Recovery. My only dilemma is I am the only nurse in the whole facility for around 20 kids. My facility also did not have a nurse before me and I'm fearful that I am not documenting when I need to along with I don't want document too much.

 

There's therapist, and  recovery counselors at my facility and then I am the nurse. They document pretty frequently. When I have a detox client I document for them the whole time they're on detox. (We are not a detox facility) Thats  only time they expect me to document I could really use advice and support.

I do have the ability to add different types of documention to our software if needed however again  I don't want too document too much but also don't want to have nothing to back me up either.

I also always document parents consent when I have to pick up new medications base off of the doctors orders