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Charting in Assisted Living

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by shannonh68 shannonh68 (New) New

I recently accepted a position as a nurse in an ALF including a memory care unit. I have been told 2 different things by 2 different nurses regarding charting and am wondering what is the standard for charting in an ALF. I have been looking up regulations and they are very vague. Help please! I feel very unsafe not knowing ...

HeyGirlHey

Specializes in Med-Surg, Oncology. Has 5 years experience.

I worked as an ALF LPN for 2 years in FL. Basically, there really wasn't a standard for charting. ALF aren't as regulated as they should be. I charted a basic head to toe including a thorough skin check upon admission or readmission from the hospital or SNF. That way, you have a baseline for that resident. After that, I charted only on changes of condition such falls, medication changes, illness, etc. Then I would chart subjective and objective data, interventions, and outcomes.

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

I used exceptions-based charting, but did a full assessment on admission and changes of condition. I also did wound assessments weekly even though home health nurses performed the actual dressing changes. ALF documentation isn't universal; each facility has its own policies regarding charting. Like the PP said, ALFs aren't regulated as they ought to be, but states are beginning to tighten up on standards of care.