Charting Help/Tips Please! for long term care / SNF

[wearinwhite]

Help! my first RN job is at a SNF pm shift (3-11) with 38 residents. I am barely making the med passes, treatments, neuro/vital/I&O checks for incidents before shift ends. i am having trouble charting in the 10min i have before shift report. WHAT exactly should i chart for residents with UTI's, Incidents, Wounds, just acting differently, etc? would love examples with LTC terminology. THANK YOU SO MUCH... i am a tad overwhelmed. :)

[DixieRedHead, ASN, RN]

One word.............FOCUS

Why are you charting? How about this?

UTI? Pain, temperature, complaints, odor of urine, mentation, reaction to ABT, output, what else did you do?

V/S 98.2,68,14,112,58 98% saturation on room air. Has denied pain and verbalized no complaints. Urine remains with strong odor. Mentation at baseline for this resident. No reaction noted to prescribed ABT. UOP X 4 incontinent per usual. Fluids at bedside and encouraged with med pass. Nancy Nurse RN.

Wound. What, where, dimensions, description, complaints?

V/S .......

Resident has 4 x 3 cm skin tear to right forearm. Wound is dry and free from drainage, warmth, or odor. Edges well approximated, steristrips in place. Resident denies pain, stating that area is "sore".

Remember, it's not how much you chart, it's how you chart.

[wearinwhite]

excellent! thank you!

[NamasteNurse, BSN, RN]

I was taught to state the problem and exactly what you did for the resident. If there is pain, did you medicate or position. Anxiety, meds or redirect?

Ex: Resident upset and anxious at dinnertime. Asking to "go home" and wants to speak with husband. Phone call made to husband and resident seemed calmer after that. Again expressed anxiety, crying and frightened at bedtime. PRN ativan given with + effect. Resident currently aslep (2300) with call bell within reach, floor mats in place, bed in lowest position. Will continue to monitor.