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Discussion

charting at night hellllp

Hi, I'm a new LPN charge nurse at a subacute and long term care facility. At night we are required to chart on all patients in subacute and certain long term patients for the MDS look back and whatnot, as well as falls, etc. When we have a full census, I wind up having to chart on 30+ patients who are mostly sleeping. I wish we could chart by exception! I think that charting is one of my strong points, yet working 11p-7a has left me with far less things to chart about. I most certainly chart on foleys, PICCs, VADs, IV sites, behavioral issues, prn meds, ABT, etc etc etc but when its just a pretty standard patient with no complaints who is SLEEPING i don't know what else to say. any hints? it just seems so repetitive.

ex-

"Pt rec in bed with eyes closed. Arouses easily to verbal stimuli. Respirations even and unlabored. Skin warm, dry, and intact. Offers no c/o pain or discomfort at the time. Safety measures in place. Call bell in reach. Will cont to monitor."

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    This was an issue I had as well working nights in LTC. I basically charted similiar to your example.

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    Sounds good except the "will continue to monitor".. What are you monitoring? See a lawyer can take that as a problem. The only time I chart will continue to monitor is IF there is a problem, then I also chart my interventions, VS etc through out the night.

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