charting

NOADLS · Nov 24, 2015

When charting for a fall, look at an experienced nurse's charting at the facility you are working at.

Look for any holes and use that as a template.

TheCommuter, BSN, RN · Nov 24, 2015

The style of charting you use is heavily dependent on the specialty.

So, what's your specialty? Med/surg? Long-term care? Critical care? We need this information in order to offer well-rounded responses. :)

caliotter3 · Nov 24, 2015

Ask your supervisor to show you examples at work so that you don't get slapped with a HIPAA violation accusation if caught perusing charts on your own.

nikita12 · Nov 24, 2015

LONG TERM CARE...if you can please give me example

TheCommuter, BSN, RN · Nov 24, 2015

LONG TERM CARE...if you can please give me example

I worked in long-term care for six years. Click on the link below to see my tips and pointers on charting in LTC.

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

nikita12 · Nov 25, 2015

how do w do charting in long term care facililites? i am a new nurse, still trying to figure it out? can anyone give me example what to inculde, for PM shift.

Hoosier_RN, MSN · Nov 25, 2015

It varies by facility and situation; do you chart by exception or do narrative? Ask you facility's clinical educator for specifics. But always document facts only, make sure to hit on reason documenting, like if there is a GI issue, then bowel sounds, last BM, any noted bleeding, continence vs incontinence, and nausea/vomiting/diarrhea. Be factual and succinct, use descriptions as needed. Not much help, but truly, in this age of computer documentation, and preprinted templates or computer templates, it does vary by facility.

caliotter3 · Nov 25, 2015

What did your supervisor suggest?

quiltynurse56, LPN, LVN · Nov 25, 2015

I suggest finding out what your facility says to do. We only do narratives on those who are skilled nursing and those where things are going on we need to document. Not sure if this will change when we go electronic.

Forever Sunshine, ASN, RN · Nov 28, 2015

Write what you see and know. Vitals, general appearance, med changes, appetite, pain level, comments on any wounds etc.

kbrn2002, ADN, RN · Nov 28, 2015

Charting will vary depending on what software, if any, your facility uses. General rule of thumb for incident charting [like falls] is to use an SBAR format.

S=situation. Here you will describe the incident as it occurred or how you discovered the resident if the fall was not witnessed. As in what position were they in, were they wearing proper footwear, was there a wheelchair, walker, bed or any other equipment involved, etc. An unwitnessed fall is by far the more common scenario in LTC.

B=Background. Here you will chart the res pertinent dx. Do they have dementia? Is there a history of falls? Is the resident on any anticoag therapy? If they are it is important to include this as it greatly increases the risk of bruising and/or bleeding.

A=Assessment. Here you will chart the immediate post fall assessment. Any injuries found, baseline neuro checks, ROM, etc.

R=Response. Here you will chart what you did. After assessing the resident if there are no injuries was the resident transferred back to bed, chair or standing and how did you transfer them? If there are injuries did you contact either 911 or the MD and transfer the resident to the ER? How did you get them there? Injuries or not this is also where you chart that the MD was notified of the fall [per your facility policies] and that the POA if there is one was notified. If your facility policy requires a round of neuro checks [and it should] this is where you indicate neuro's started per policy.

This is just a basic template used where I work. Our software has the SBAR template included right in the progress note section. Make sure to read up on previous fall/incident charting for your facility to see how it is done where you work and ask your more experienced co-workers for guidance the first few times you need to incident chart.

Even if your facility uses paper charting an SBAR format is easy to remember and follow, but again you will need to be guided by the preferred charting system of your facility.