charting advice

[cjkekoa]

I am an LVN, and still learning how to chart well. My resident just has a small scratch on the right side of his neck close to his tracheostomy or near his adam's apple. How could I chart this ? there is no drainage, looks superficial. the shift before me did not endorse this and I noted it during trach care.

[mariebailey, MSN, RN]

I would think describing it like any other wound would be sufficient. Example: Superficial 10 x 1 x 1 abrasion noted on right side of neck close to tracheostomy. No erythema, drainage, or swelling. Cleaned with normal saline & left uncovered & dry. Plan to monitor.

[cjkekoa]

Thanks so much.

[mariebailey, MSN, RN]

https://allnurses.com/geriatric-nurses-ltc/ltc-charting-beginners-899111.html

[TheCommuter, BSN, RN]

My resident just has a small scratch on the right side of his neck close to his tracheostomy or near his adam's apple. How could I chart this ? the shift before me did not endorse this and I noted it during trach care

The shift before you probably didn't endorse it because a mountain of tasks are associated with documenting a skin variance in the hyperregulated world of LTC.

1. You document the existence of the skin variance in your nursing notes.

2. Depending on facility policy, you prepare an incident report.

3. Depending on facility policy, you notify the responsible party and physician.

4. To cover your behind, you obtain orders (e.g. "Cleanse scratch to neck with wound cleanser, pat dry with gauze and leave open to air daily for 14 days").

5. You transcribe the orders onto the MAR, TAR or computerized charting system, depending on what your facility uses.

So I see why the previous shift didn't endorse the scratch to the neck. Click on the link below to read more about LTC charting.

LTC Charting: a Beginner's Guide