Charting question..

suespets · Apr 13, 2008

I'll start off by telling you what a nurse told me just the other day..... don't chart 'will monitor 'unless you make another entry verifying that you did monitor, later on.I've charted' continue to monitor 'for yr's( meaning we as nurses on each shift are closely monitoring said resident) btw no lawer ever complained.lol!!!!! If your talking about weekly charting, I find reading through the cna books helpful. My general rule for weekly charting is anyone who read my charting could pick out who exactly, I was charting about,given that they know all the residents.admittedly, this is not always time effective!

Midwest4me · Apr 13, 2008

i had posted this on another thread but didn't get a response... i was wondering if some of you can shine some light on this:
i just started working at an ltc, i'm a brand new nurse and finally got a job. i like all your guys' responses on how and what to chart... but would you chart that on all of your pts??? not necessarily; chart to the main problems. i was taught to chart: "pt. alert and oriented (or confused), able tomake needs known. no c/o pain or discomfort. no signs of distress noted. respirations even and unlabored. all needs met and attended by staff. all meds given as ordered. call light within reach. will continue to monitor."
and then you can add...
"cont. on antibiotic therapy, with no adverse side effects..."
"pt. c/o pain 6/10, gave so and so med as ordered..."
i don't know if this is right, i'm really nervous that some day some lawyer pulls my charts and finds out that most of them sound the same. i try to vary every now and then but i feel like i'm missing something, like something is wrong. it is pretty scary. after you give pain med... do you chart if it was effective or not? yes, you need to document the effect of the med; usually that's done on the reverse side of the mar in the prn notes. you can also chart this in the progress/nursing notes if need be; i.e., if you're the charge nurse too. what other things would you chart on. focus on the primary problem and any contributing issues. i'm only passing meds, so my contact with the pt is usually minimal. isn't the charge nurse the one doing the primary charting? when i passed meds, i rarely had to chart in their charts unless something adverse occurred with regard to their meds; usually i just charted the effects of the prn meds on the reverse side of the mar in the prn notes.
if you were in the same situation and found a way to organize your charting/your day, i would love to read some suggestions.
please help!!! :uhoh21:

hope the above helps; good luck with your new job!

PsychNurseWannaBe, BSN, RN · Apr 13, 2008

Try not to use a "canned" charting method. It is too closed ended and will probably lead to frustration. Chart what you see, as well as, subjective data. If you need to add more later in the shift...go ahead and add it. It is ok to have multiple entries. Health is dynamic.

We chart on new admits, new medication like ATB, change in condition, Medicare, etc... I do not chart on every resident every night. Sometimes there isn't anyone on report, so charting is very minimal.

One thing that normally is always in my charting is the patients VS. Because again... I am charting because of something that needs to be watched for several shifts.

Stay away from "ALL"... all meds given, all needs met. That will set you up. If someones finds only ONE thing not done...your credability can be called into question. Additionally there is no reason really to double chart. Your MAR and TAR demonstrate what medications and treatments you provide and is already a part of the patient's chart.

However, I will chart if I gave a PRN med and if it was effective. Because I provided an intervention, and I was taught you should have an outcome for any intervention you provide. It's part of the nursing process... evaluation. So I would chart something like... "Resident complained of having a headache. Rated pain 7/10. Provided PRN pain med which was effective. Currently Resident says pain is 2/10." I do not chart what PRN pain med I give because the MAR will show what I gave. I don't want to accidently chart a wrong drug or dose, even though I gave the right drug and right dose.

I also do this when I receive orders from MDs. I will write out the phone order. Transcribe it onto the MAR and POS but then I chart. "Received new orders from MD regarding blood pressure, see MAR/POS."

It takes time to get the hang of LTC and its charting.

>--stethoscope--o · Apr 13, 2008

I'm a nursing student and what my teacher told me was something not charted is care not given, even though you performed pt care. So yeah, I would chart that the med was effective by stating what the pain is after 30 min. of giving the med. ex. (time, date)- Pain med administered at____. with a pain rated at 9/10. (time, date)-Pain rated 5/10. [i'm pretty sure the time would talk for it self that you went and check whether the pain had subsided.] [if I'm wrong on this someone please correct me.]

As far as advice on changing up the way you chart and making sure you got everything... On our first day of clinicals this semester our teacher gaves us a lecture on charting in the hospital and she told us an easy way to remember we got everything is by starting with what you see first. The surrounding/environment, then go to the face (1-eyes, 2-nose, 3-ears, 4-mouth), then after that go down, to the neck, then to the chest (heart, lungs). After that GI, GU, and your extremities last. If there are wounds indicate them where they are at like if there is a sore on the left nare state it when your talking about the nose. [Pretty much start from the head and go on down and then out into the extremeties] By doing this you won't miss anything. Hope this helps.

vivibonita · Apr 13, 2008

I see what you say Striver and I was also taugt the same thing, but this is first a different setting and a different situation. And there's where my confusion comes. All these things we are taught are usually not applicable to real life.

I'm a nursing student and what my teacher told me was something not charted is care not given, even though you performed pt care. So yeah, I would chart that the med was effective by stating what the pain is after 30 min. of giving the med. ex. (time, date)- Pain med administered at____. with a pain rated at 9/10. (time, date)-Pain rated 5/10. [i'm pretty sure the time would talk for it self that you went and check whether the pain had subsided.] [if I'm wrong on this someone please correct me.]
As far as advice on changing up the way you chart and making sure you got everything... On our first day of clinicals this semester our teacher gaves us a lecture on charting in the hospital and she told us an easy way to remember we got everything is by starting with what you see first. The surrounding/environment, then go to the face (1-eyes, 2-nose, 3-ears, 4-mouth), then after that go down, to the neck, then to the chest (heart, lungs). After that GI, GU, and your extremities last. If there are wounds indicate them where they are at like if there is a sore on the left nare state it when your talking about the nose. [Pretty much start from the head and go on down and then out into the extremeties] By doing this you won't miss anything. Hope this helps.

PsychNurseWannaBe, BSN, RN · Apr 13, 2008

I see what you say Striver and I was also taugt the same thing, but this is first a different setting and a different situation. And there's where my confusion comes. All these things we are taught are usually not applicable to real life.

Boy did you hit the nail on the head!

VIVI,

I understand where you are coming from in LTC. I just graduated in Dec. and I too ran into the same problems you are having. I would sit at the computer and stare at my screen thinking...what am I supposed to chart? I would stress myself out. I have learned to just sit back and relax....then chart. Normally when I have people on report, I will check them out when I am doing my med pass. For the most part it is going to be a focus assessment.

Read some of your co-workers charting. It will help you learn.

CoffeeRTC, BSN, RN · Apr 14, 2008

Ask your MDS nurse for help....you will get tons of advice.

LTC charting is a bit different than acute. First off...tons more pts to chart on and alot of the times...not much has changed.

In LTC..you need documentation for the MDS or skilled charting. Why are they being skilled? Therapy, wound care, med management. Start off by looking at the main Dx. Think about what you should be looking at in relation to the main dx. Most places the MDS nurse/ RNAC will have a list of what you should be charting on and it will be in the chart or posted somewhere, if they don't..again...I'm sure they would be glad to give you cheat sheets (I know when was an RNAC...I would kill to have someone document what I actually needed!)

Another thing to document is any new orders, if you called the doc and or famillies to let them know of the changes in condition and what resulted from the calls.

Sometimes we over document. In LTC there seems to be tons and tons of forms. If giving a PRN med...noting it on the back of the MAR and then most MARs will have a place to evaluate the response to the meds on the back.

Having a cheat sheet with all the res names on it helps too. I get a census form with all my res names on it. Beside the names I will note things I received in report then as I go during a med pass...I will make notes on that form. At the end of the shift or when I get time to chart, I will use that to jog my memory.

vivibonita · Apr 14, 2008

I have looked at my coworkers' charting and it sounds exactly the same as what I put on the opening post. I just dont want my charting to sound SO repetitive, and/or the same as my coworkers. This is quite frustrating, but like you said I will soon get the handle of it.

Oh! what can I put instead of "will continue to monitor" ?

PsychNurseWannaBe, BSN, RN · Apr 14, 2008

I have looked at my coworkers' charting and it sounds exactly the same as what I put on the opening post. I just dont want my charting to sound SO repetitive, and/or the same as my coworkers. This is quite frustrating, but like you said I will soon get the handle of it.
Oh! what can I put instead of "will continue to monitor" ?

I worked for a place where the nurses pretty much charted the same thing...over and over again. I was in your shoes once and I would look at their charting and think...umm, that wasn't much help. LOL

Maybe what could help is to think what their dx are and what meds they are taking. For example if someone is experiencing high blood pressure and they are on report...open up your drug book and look at nursing considerations for BP meds. It should tell you what to look for/assess. Chart on that.

My nursing drug books really helped me out.

I have been thinking of your post the past day or two and been trying to think of ways to help ya... I think of good things to say and then I get home and forget them. Sorry.

Do you still have your Health Assessment book from school? Also, glance at your pathophys book. In order to chart, you have to have a good understanding of the disease and the human response.

For example... I had someone with low blood pressure. So I charted VS and if they had symptoms of low BP. Then I charted what their output was. Low blood pressure leads to low GFR which can decrease your output if BP is low enough. Then I contacted the MD per order...and charted that I spoke with MD and received orders.

Sometimes charting is a small little quip and sometimes it is long. I actually find that my charting is longer on people who refuse interventions because you have to chart everything in case the person goes "down hill" and you have to cover your butt.

I never mention anything about "continue to montior". As the OP stated, you would need to then chart again that you did in fact continue to monitor. Is it ok to leave that quip totally out.

suespets · Apr 15, 2008

vivabonita:skip the whole will monitor thing(this really is a given,right?) just check the resident and chart findings before you go off shift..Can be (if true)sleeping w/ even respirations. no noted discomfort.

sasha2lady · Dec 16, 2009

I was told by a rn to never chart " will continue to monitor" she said it's ok as long as you word it " will continue to monitor and chart any changes" from notes ive read I'm the only nurse at work who words it like this but like another poster replied what if there's no note that the pt was monitored after said event (pain fall skintear etc) CYA .